Provider Demographics
NPI:1972513307
Name:WILSON, P DARLEANE (PA-C)
Entity Type:Individual
Prefix:
First Name:P DARLEANE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 124
Mailing Address - Street 2:
Mailing Address - City:TOWNSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27584-0124
Mailing Address - Country:US
Mailing Address - Phone:252-432-5750
Mailing Address - Fax:252-430-7352
Practice Address - Street 1:864 US HWY 158 BUSINESS WEST
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:NC
Practice Address - Zip Code:27589-9879
Practice Address - Country:US
Practice Address - Phone:910-524-3690
Practice Address - Fax:252-257-5164
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102532363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q40643Medicare UPIN