Basic Information
| Provider Information | |||||||||
| NPI: | 1114564036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JUSTINE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 217 WILD ONION LN | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761312490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172296663 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3645 WESTERN CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761371944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172329767 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2019 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.