Healthcare Provider Details

I. General information

NPI: 1235188301
Provider Name (Legal Business Name): TERRY ROGER WILSON P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 OLIVER RD
MONROE LA
71201-5702
US

IV. Provider business mailing address

130 DESIARD ST SUITE 355
MONROE LA
71201-7319
US

V. Phone/Fax

Practice location:
  • Phone: 318-812-7559
  • Fax: 318-812-7563
Mailing address:
  • Phone: 318-807-7875
  • Fax: 318-812-6603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number200134
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTT.Z11857
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: