Provider Demographics
NPI:1548024029
Name:WILSON, SAMUEL JEROD (PA-C)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JEROD
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12324 MATTHEWS LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127-1344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 E PRIMROSE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5154
Practice Address - Country:US
Practice Address - Phone:314-269-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024004739363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant