Provider Demographics
NPI:1902140593
Name:WILSON, SHAUN MARIE TANIKA (PAC)
Entity Type:Individual
Prefix:
First Name:SHAUN MARIE
Middle Name:TANIKA
Last Name:WILSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1442 E 84TH ST
Mailing Address - Street 2:2FL
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-5128
Mailing Address - Country:US
Mailing Address - Phone:347-866-7357
Mailing Address - Fax:
Practice Address - Street 1:1442 E 84TH ST
Practice Address - Street 2:2FL
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-5128
Practice Address - Country:US
Practice Address - Phone:347-866-7357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0162481363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant