Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | 036-122350 | IL |
N | 207ND0900X | Dermatopathologist | 036-122350 | IL |
NPI | 1538327556 |
---|---|
Provider Name | Dr. Morgan Wilson |
First Address | Springfield, IL 62794-9644 |
Second Address | Springfield, IL 62702-4968 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/05/2008 |
Last Update Date | 04/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036122350 | (05) | IL |