Provider Demographics
NPI:1679305478
Name:WILSON, JAIMIN (PA)
Entity type:Individual
Prefix:
First Name:JAIMIN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 WATER ST APT 1509
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02141-1399
Mailing Address - Country:US
Mailing Address - Phone:401-864-1689
Mailing Address - Fax:
Practice Address - Street 1:200 NASHUA ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-1105
Practice Address - Country:US
Practice Address - Phone:617-635-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-19
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant