Provider Demographics
NPI:1982643243
Name:WILSON, GAVIN KEITH (PA)
Entity Type:Individual
Prefix:MR
First Name:GAVIN
Middle Name:KEITH
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1898 NW AZALEA ST
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-9202
Mailing Address - Country:US
Mailing Address - Phone:772-692-4577
Mailing Address - Fax:
Practice Address - Street 1:1800 SE TIFFANY AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7521
Practice Address - Country:US
Practice Address - Phone:772-398-3800
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102199363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P73598Medicare UPIN