Provider Demographics
NPI:1861517575
Name:WILSON, CHRISTY PEARL (PA)
Entity type:Individual
Prefix:
First Name:CHRISTY
Middle Name:PEARL
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHRISTY
Other - Middle Name:A
Other - Last Name:PEARL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:3820 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1110
Mailing Address - Country:US
Mailing Address - Phone:770-948-5409
Mailing Address - Fax:770-948-6774
Practice Address - Street 1:3820 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1110
Practice Address - Country:US
Practice Address - Phone:770-948-6041
Practice Address - Fax:770-819-2987
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003863363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP58721Medicare UPIN