Provider Demographics
NPI:1861439523
Name:WILSON, SIDNEY RODOLFO (PA12)
Entity Type:Individual
Prefix:
First Name:SIDNEY
Middle Name:RODOLFO
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA12
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:448 E 45TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-4120
Mailing Address - Country:US
Mailing Address - Phone:718-287-5450
Mailing Address - Fax:
Practice Address - Street 1:4115 162ND ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-4124
Practice Address - Country:US
Practice Address - Phone:718-762-6640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006481363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical