Provider Demographics
NPI:1861614109
Name:WILSON, TERESA LYNNE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:LYNNE
Last Name:WILSON
Suffix:
Gender:F
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 1:801 E NOLANA AVE STE 13A
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-6112
Mailing Address - Country:US
Mailing Address - Phone:956-686-2700
Mailing Address - Fax:956-686-2708
Practice Address - Street 1:1315 W MAIN AVE STE 13A
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:TX
Practice Address - Zip Code:78573-1642
Practice Address - Country:US
Practice Address - Phone:956-432-0222
Practice Address - Fax:956-583-2226
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA 01815363AM0700X
TXPA01815363A00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX285326902Medicaid
TX285326902Medicaid