Provider Demographics
NPI:1881775898
Name:WILSON, TRINA LORIN (PA-C)
Entity type:Individual
Prefix:
First Name:TRINA
Middle Name:LORIN
Last Name:WILSON
Suffix:
Gender:F
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 365
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753-0365
Mailing Address - Country:US
Mailing Address - Phone:802-349-0516
Mailing Address - Fax:
Practice Address - Street 1:1436 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-4497
Practice Address - Country:US
Practice Address - Phone:802-388-3194
Practice Address - Fax:802-388-4881
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550031008363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical