Healthcare Provider Details

I. General information

NPI: 1215908496
Provider Name (Legal Business Name): GINA LYNNE WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67252 INDUSTRY LN STE 100
COVINGTON LA
70433-8704
US

IV. Provider business mailing address

65 JUNIPER CT
MANDEVILLE LA
70471-6795
US

V. Phone/Fax

Practice location:
  • Phone: 985-801-6212
  • Fax:
Mailing address:
  • Phone: 985-801-6216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD201912
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: