Basic Information
| Provider Information | |||||||||
| NPI: | 1821336306 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1430 | ||||||||
| Address2: | |||||||||
| City: | HARRISONBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 228031430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406895500 | ||||||||
| FaxNumber: | 7574317116 | ||||||||
| Practice Location | |||||||||
| Address1: | 2509 PLEASANT RUN DR | ||||||||
| Address2: | |||||||||
| City: | ROCKINGHAM | ||||||||
| State: | VA | ||||||||
| PostalCode: | 228018720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406895500 | ||||||||
| FaxNumber: | 7574317116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2013 | ||||||||
| LastUpdateDate: | 02/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0110004140 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1821336306 | 05 | VA | MEDICAID |