Provider Demographics
NPI:1841470507
Name:WILSON, KEITH ALAN (PA)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ALAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:12143 NAVAJO RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-7250
Mailing Address - Country:US
Mailing Address - Phone:760-240-1144
Mailing Address - Fax:760-240-9127
Practice Address - Street 1:12550 HESPERIA ROAD
Practice Address - Street 2:SUITE100
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-0000
Practice Address - Country:US
Practice Address - Phone:760-241-6666
Practice Address - Fax:760-241-7575
Is Sole Proprietor?:No
Enumeration Date:2007-11-11
Last Update Date:2019-03-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAPA18722363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant