Provider Demographics
NPI:1023102530
Name:WILCOX, DONNA CATHERINE (PAC)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:CATHERINE
Last Name:WILCOX
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3829 N HWY 3
Mailing Address - Street 2:
Mailing Address - City:ETNA
Mailing Address - State:CA
Mailing Address - Zip Code:96027-9524
Mailing Address - Country:US
Mailing Address - Phone:707-268-8502
Mailing Address - Fax:
Practice Address - Street 1:3829 N HWY 3
Practice Address - Street 2:
Practice Address - City:ETNA
Practice Address - State:CA
Practice Address - Zip Code:96027-9524
Practice Address - Country:US
Practice Address - Phone:707-268-8502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13092363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ53772Medicare UPIN