Provider Demographics
NPI:1356716146
Name:WILSON, EMILY ELIZA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:ELIZA
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:EMILY
Other - Middle Name:ELIZA
Other - Last Name:GLENN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:313 3RD ST W
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:MN
Mailing Address - Zip Code:55352-1425
Mailing Address - Country:US
Mailing Address - Phone:612-466-0922
Mailing Address - Fax:
Practice Address - Street 1:1961 PREMIER DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6492
Practice Address - Country:US
Practice Address - Phone:507-387-2939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-06
Last Update Date:2015-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11985363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant