Healthcare Provider Details

I. General information

NPI: 1366861908
Provider Name (Legal Business Name): LAURA GRACE WILSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3049
US

IV. Provider business mailing address

49 JESSE HILL JR DR SE
ATLANTA GA
30303-3049
US

V. Phone/Fax

Practice location:
  • Phone: 352-627-9350
  • Fax:
Mailing address:
  • Phone: 404-778-1415
  • Fax: 404-778-1401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberME132997
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: