Provider Demographics
NPI:1700067378
Name:WILSON, CARY B (PA-C)
Entity type:Individual
Prefix:MR
First Name:CARY
Middle Name:B
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 1:1179 N MCDOWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6559
Mailing Address - Country:US
Mailing Address - Phone:707-559-7500
Mailing Address - Fax:
Practice Address - Street 1:5900 STATE FARM DR STE 200
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2149
Practice Address - Country:US
Practice Address - Phone:707-559-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-23
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56256207Q00000X
MT56256363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1700067378Medicaid
MT1700067378Medicare PIN