Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2100X | Nurse Practitioner - Acute Care | 21430 | SC |
NPI | 1013420900 |
---|---|
Provider Name | Randall Ann Wilson |
First Address | Columbia, SC 29209-1638 |
Second Address | Columbia, SC 29209-1638 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/11/2017 |
Last Update Date | 14/11/2017 |