Provider Demographics
NPI:1295456770
Name:WILSON, KADINE TASHIKA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KADINE
Middle Name:TASHIKA
Last Name:WILSON
Suffix:
Gender:F
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 1:11141 TORTUGA BND APT 106
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-6184
Mailing Address - Country:US
Mailing Address - Phone:195-477-0354
Mailing Address - Fax:
Practice Address - Street 1:11141 TORTUGA BND APT 106
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-6184
Practice Address - Country:US
Practice Address - Phone:954-770-3544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
FL9116408363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical