Individual
JERRY DEWAYNE WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
4500 HUGH HOWELL RD, SUITE, TUCKER, GA 30084-4723
(678) 632-4003
(678) 681-1305
Mailing address
PO BOX 360550, DECATUR, GA 30036-0550
(678) 632-4003
(678) 681-1305
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
003052
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
308036587A
—
GA
Enumeration date
01/14/2008
Last updated
12/06/2010
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