Provider Demographics
NPI:1043324148
Name:WILSON, CASEY V (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:V
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:V
Other - Last Name:PROCTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:999 W PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3134
Mailing Address - Country:US
Mailing Address - Phone:386-740-7080
Mailing Address - Fax:386-734-0821
Practice Address - Street 1:999 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3134
Practice Address - Country:US
Practice Address - Phone:386-740-7080
Practice Address - Fax:386-734-0821
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2019-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103729363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant