Provider Demographics
NPI:1245297340
Name:WILSON, LARRY TODD (PA-C)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:TODD
Last Name:WILSON
Suffix:
Gender:M
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 1:2600 WESTHALL LN
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7102
Mailing Address - Country:US
Mailing Address - Phone:407-200-2300
Mailing Address - Fax:407-303-0580
Practice Address - Street 1:2600 WESTHALL LN
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7102
Practice Address - Country:US
Practice Address - Phone:407-200-2300
Practice Address - Fax:407-303-0580
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA-9110091363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV959OtherWV LICENSE