Provider Demographics
NPI:1063268209
Name:RODRIGUEZ, WILSON OMAR (PA)
Entity type:Individual
Prefix:DR
First Name:WILSON
Middle Name:OMAR
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 532
Mailing Address - Street 2:
Mailing Address - City:LAKE ALFRED
Mailing Address - State:FL
Mailing Address - Zip Code:33850-0532
Mailing Address - Country:US
Mailing Address - Phone:407-315-3637
Mailing Address - Fax:407-358-3440
Practice Address - Street 1:217 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-6312
Practice Address - Country:US
Practice Address - Phone:407-315-3637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-29
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR2146-PA363A00000X
FLTPPA690363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant