Provider Demographics
NPI:1336251925
Name:WILSON, JENNIFER BANTLEY (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BANTLEY
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5692 ABERDEEN DR
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17111-4730
Mailing Address - Country:US
Mailing Address - Phone:717-671-0518
Mailing Address - Fax:
Practice Address - Street 1:5692 ABERDEEN DR
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17111-4730
Practice Address - Country:US
Practice Address - Phone:717-671-0518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-005544-L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC34146Medicare UPIN