Provider Demographics
NPI:1023829439
Name:ROMAN, WILSON EMMANUEL (PA-C)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:EMMANUEL
Last Name:ROMAN
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 1:14347 EARLINE RD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34614-2025
Mailing Address - Country:US
Mailing Address - Phone:407-529-4454
Mailing Address - Fax:
Practice Address - Street 1:14347 EARLINE RD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34614-2025
Practice Address - Country:US
Practice Address - Phone:407-529-4454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant