Provider Demographics
NPI:1881968840
Name:WILSON, VICTORIA E
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5030 CHAMPION BLVD STE G11-535
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-2473
Mailing Address - Country:US
Mailing Address - Phone:561-235-7666
Mailing Address - Fax:561-948-0989
Practice Address - Street 1:2900 N MILITARY TRL STE 241
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6347
Practice Address - Country:US
Practice Address - Phone:561-235-7666
Practice Address - Fax:561-948-0989
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106455363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant