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NPI Code Detail

MEDICARE: PETER DAVID WILSON

MEDICARE: PETER DAVID WILSON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician AssistantMPA.3364SC

General Provider Information

NPI Number : 1801447412
Entity Type Code : Individual
Provider Name (Legal Business Name) : PETER DAVID WILSON
Provider Business Mailing Address
First Line : PO BOX 751461
Second Line :
City : CHARLOTTE
State : NC
Zip : 28275-1461
Country : US
Telephone Number : 843-792-6200
Fax Number :
Provider Business Practice Location Address
First Line : 171 ASHLEY AVE
Second Line :
City : CHARLESTON
State : SC
Zip : 29425-8908
Country : US
Telephone Number : 843-792-9707
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/25/2019
Last Update Date : 12/02/2019

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