Healthcare Provider Details

I. General information

NPI: 1093925703
Provider Name (Legal Business Name): JOYCE MARIE WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W STADIUM BLVD
JEFFERSON CITY MO
65109-6003
US

IV. Provider business mailing address

PO BOX 104240
JEFFERSON CITY MO
65110-4240
US

V. Phone/Fax

Practice location:
  • Phone: 573-635-8000
  • Fax: 573-556-1710
Mailing address:
  • Phone: 573-635-5264
  • Fax: 573-556-1710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberBB4745785-2005013504
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number2011000670
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: