Provider Demographics
NPI:1487772075
Name:WILSON, SUSAN LEE (PA-C)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LEE
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 1:55 BUCKEYE COVE RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28716-4511
Mailing Address - Country:US
Mailing Address - Phone:828-648-0282
Mailing Address - Fax:828-648-3479
Practice Address - Street 1:55 BUCKEYE COVE RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NC
Practice Address - Zip Code:28716-4511
Practice Address - Country:US
Practice Address - Phone:828-648-0282
Practice Address - Fax:828-648-3479
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101481363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101745Medicaid