Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QA0401X | Family Doctor - Addiction Medicine | OS-004237-L | PA |
N | 207QG0300X | Family Doctor - Geriatric Medicine | OS-004237-L | PA |
N | 208D00000X | General Practice Physician | OS-004237-L | PA |
NPI | 1245216068 |
---|---|
Provider Name | Robert S Wilson |
First Address | Eagleville, PA 19403-1829 |
Second Address | Eagleville, PA 19403-1829 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/12/2005 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C23646 | (02) | PA |