Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | 047279 | GA |
NPI | 1053486456 |
---|---|
Provider Name | Dr. Dawn Wilson |
First Address | Lake City, GA 30260-3553 |
Second Address | Lake City, GA 30260-3553 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H00060 | (02) | GA |