Healthcare Provider Details

I. General information

NPI: 1780546648
Provider Name (Legal Business Name): LANDON B. WILSON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 RIVER OAKS DR
CANTON MS
39046-5375
US

IV. Provider business mailing address

148 CEDAR SPRING CIR
PEARL MS
39208-8603
US

V. Phone/Fax

Practice location:
  • Phone: 601-951-6530
  • Fax:
Mailing address:
  • Phone: 601-951-6530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number884790
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: