Healthcare Provider Details

I. General information

NPI: 1750761532
Provider Name (Legal Business Name): GRACE WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRACE CARLSON MD

II. Dates (important events)

Enumeration Date: 06/05/2015
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 E BROADWAY STE 280
COLUMBIA MO
65201-7185
US

IV. Provider business mailing address

1705 E BROADWAY STE 280
COLUMBIA MO
65201-7185
US

V. Phone/Fax

Practice location:
  • Phone: 573-815-7119
  • Fax: 573-815-7116
Mailing address:
  • Phone: 573-815-7119
  • Fax: 573-815-7116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2015017097
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2021030232
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: