Provider Demographics
NPI:1891098927
Name:WILSON, NIKEETA
Entity Type:Individual
Prefix:
First Name:NIKEETA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6424 CENTRAL CITY BLVD APT 732
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77551-2071
Mailing Address - Country:US
Mailing Address - Phone:210-324-4578
Mailing Address - Fax:
Practice Address - Street 1:6900 BRODIE LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-5008
Practice Address - Country:US
Practice Address - Phone:713-935-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-12
Last Update Date:2010-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant