Healthcare Provider Details

I. General information

NPI: 1841794567
Provider Name (Legal Business Name): LAURA ANN WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S MAIN ST STE 525
ORANGE CA
92868-4553
US

IV. Provider business mailing address

33601 WINDJAMMER DR
DANA POINT CA
92629-4469
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-5631
  • Fax: 714-285-0389
Mailing address:
  • Phone: 714-742-3245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0207X
TaxonomyMedical Biochemical Genetics
License NumberA165832
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberA165832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: