Provider Demographics
NPI:1255701389
Name:WILSON, LAUREN (PA-C)
Entity type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:ELIZABETH
Other - Last Name:MATHEWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1348 WALTON WAY
Mailing Address - Street 2:SUITE 5100
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-5104
Mailing Address - Country:US
Mailing Address - Phone:706-724-8611
Mailing Address - Fax:706-724-6202
Practice Address - Street 1:1348 WALTON WAY
Practice Address - Street 2:SUITE 5100
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-5104
Practice Address - Country:US
Practice Address - Phone:706-724-8611
Practice Address - Fax:706-724-5205
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA35399363AM0700X
GA007764363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical