Provider Demographics
NPI:1548735228
Name:WILSON, TARAH E (PA)
Entity type:Individual
Prefix:
First Name:TARAH
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TARAH
Other - Middle Name:E
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4411 MEDICAL DR STE 120
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3829
Mailing Address - Country:US
Mailing Address - Phone:210-614-5400
Mailing Address - Fax:210-614-2413
Practice Address - Street 1:4411 MEDICAL DR STE 120
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3829
Practice Address - Country:US
Practice Address - Phone:210-614-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
TXPA12496363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant