Individual
DESTONEE WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
1650 S BEACH ST, FORT WORTH, TX 76105
(817) 702-1100
(817) 702-6124
Mailing address
PO BOX 732973, DALLAS, TX 75373-2973
(817) 702-8450
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
279726-1206
UT
363A00000X
Physician Assistant
Primary
PA12177
TX
Other
Enumeration date
09/06/2017
Last updated
11/07/2018
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