Basic Information
| Provider Information | |||||||||
| NPI: | 1831160332 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 850001 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328850192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042826331 | ||||||||
| FaxNumber: | 9042824117 | ||||||||
| Practice Location | |||||||||
| Address1: | 1821 BLANDING BLVD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MIDDLEBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320683839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044063160 | ||||||||
| FaxNumber: | 9044063159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 11/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA2944 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.