Provider Demographics
NPI:1447070453
Name:WILSON, CARLIE ANN (PA-C)
Entity type:Individual
Prefix:
First Name:CARLIE
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:1170 E BELVIDERE RD STE 206
Practice Address - Street 2:
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2076
Practice Address - Country:US
Practice Address - Phone:224-541-8120
Practice Address - Fax:224-541-8121
Is Sole Proprietor?:No
Enumeration Date:2024-10-14
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI8312-23363A00000X
IL085.010746363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant