Provider Demographics
NPI:1831160332
Name:WILSON, DANIEL G (PA-C)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:G
Last Name:WILSON
Suffix:
Gender:M
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:PO BOX 850001
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32885-0192
Mailing Address - Country:US
Mailing Address - Phone:904-282-6331
Mailing Address - Fax:904-282-4117
Practice Address - Street 1:1821 BLANDING BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-3839
Practice Address - Country:US
Practice Address - Phone:904-406-3160
Practice Address - Fax:904-406-3159
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2944363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP33732Medicare UPIN
FLE5674YOtherPTAN
FLK5587OtherMEDICARE GROUP