Provider Demographics
NPI:1205239803
Name:WILSON, AMBER LEE (PA-C)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:LEE
Other - Last Name:KUKLINSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5407 ENCINO OAK WAY
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-5952
Mailing Address - Country:US
Mailing Address - Phone:218-791-7011
Mailing Address - Fax:
Practice Address - Street 1:5407 ENCINO OAK WAY
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-5952
Practice Address - Country:US
Practice Address - Phone:218-791-7011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-27
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4479363AM0700X
HIAMD 652363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical