Provider Demographics
NPI:1861453490
Name:WILSON, GENA R (PNP)
Entity Type:Individual
Prefix:
First Name:GENA
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:GENA
Other - Middle Name:R
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3200 E CAMELBACK RD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2327
Mailing Address - Country:US
Mailing Address - Phone:602-933-1813
Mailing Address - Fax:
Practice Address - Street 1:1920 E CAMBRIDGE AVE STE 304
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006
Practice Address - Country:US
Practice Address - Phone:602-933-4363
Practice Address - Fax:602-933-2415
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN060806363LP0200X
AZAP6776363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ863177Medicaid