Provider Demographics
NPI:1780715896
Name:WILSON, CARMEN ANN (PA)
Entity type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-454-8304
Mailing Address - Fax:314-454-5902
Practice Address - Street 1:4500 FOREST PARK AVE
Practice Address - Street 2:DIV IM BONE MARROW TRANSPLANT, 5TH, 6TH, 8TH FL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2114
Practice Address - Country:US
Practice Address - Phone:314-454-8304
Practice Address - Fax:314-454-5902
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000145768363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220024269Medicaid