Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0122X | Plastic and Reconstructive Surgery | ME 84966 | FL |
NPI | 1023238243 |
---|---|
Provider Name | Dr. Ian Fitzsimmons Wilson |
First Address | St Petersburg, FL 33703 |
Second Address | Baypines, FL 33744 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/04/2007 |
Last Update Date | 08/07/2007 |