Provider Demographics
NPI:1760266373
Name:WILSON, WESLEY (PA-C)
Entity type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:
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 1:4930 E LAKE MARY BLVD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-5003
Mailing Address - Country:US
Mailing Address - Phone:407-322-8645
Mailing Address - Fax:833-314-0572
Practice Address - Street 1:4930 E LAKE MARY BLVD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-5003
Practice Address - Country:US
Practice Address - Phone:407-322-8645
Practice Address - Fax:407-269-8986
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9117569363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant