Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 0101254102 | VA |
Y | 208600000X | Surgeon | 0101254102 | VA |
N | 2086X0206X | Surgical Oncologist | E-7047 | AR |
NPI | 1407035629 |
---|---|
Provider Name | Misti H Wilson |
First Address | Midlothian, VA 23114-0002 |
Second Address | Midlothian, VA 23114-0002 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/10/2007 |
Last Update Date | 01/08/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C09633 | GROUP PTAN (01) | VA |