Provider Demographics
NPI:1174041578
Name:WILSON, DESTONEE (PA-C)
Entity type:Individual
Prefix:
First Name:DESTONEE
Middle Name:
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:PO BOX 732973
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-2973
Mailing Address - Country:US
Mailing Address - Phone:817-702-8450
Mailing Address - Fax:
Practice Address - Street 1:1650 S BEACH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76105
Practice Address - Country:US
Practice Address - Phone:817-702-1100
Practice Address - Fax:817-702-6124
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT279726-1206363A00000X
TXPA12177363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant