1194016857 NPI number — MS. NANCY JOANN WILSON P.A. PHYSICIAN ASSIS

Table of content: MS. NANCY JOANN WILSON P.A. PHYSICIAN ASSIS (NPI 1194016857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194016857 NPI number — MS. NANCY JOANN WILSON P.A. PHYSICIAN ASSIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
NANCY
Provider Middle Name:
JOANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
P.A. PHYSICIAN ASSIS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PRINDLE
Provider Other First Name:
NANCY
Provider Other Middle Name:
WILSON
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194016857
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2311 W. MORRISON AVE #27
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-893-9698
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3838 W. NEPTUNE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-893-9698
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA9105925 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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