Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 27103 | SC |
Y | 207QS0010X | Family Doctor - Sports Medicine | 27103 | SC |
NPI | 1235255266 |
---|---|
Provider Name | Michelle Margarita Wilson |
First Address | Greenville, SC 29601-2842 |
Second Address | Greenville, SC 29615-6322 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/03/2007 |
Last Update Date | 23/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
271039 | (05) | SC |