Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207SG0201X | Clinical Genetics (M.D.) | MD049539L | PA |
NPI | 1316979131 |
---|---|
Provider Name | James M Wilson |
First Address | Philadelphia, PA 19104-3413 |
Second Address | Philadelphia, PA 19104-4206 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2006 |
Last Update Date | 11/12/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001478725 | (05) | PA |
E35702 | (02) | PA |