Healthcare Provider Details

I. General information

NPI: 1003841354
Provider Name (Legal Business Name): JAMES KEENAN WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 VETERANS MEMORIAL BLVD S
EUPORA MS
39744-2215
US

IV. Provider business mailing address

307 COLLEGE ST
WINONA MS
38967-1901
US

V. Phone/Fax

Practice location:
  • Phone: 662-258-6221
  • Fax: 662-258-9291
Mailing address:
  • Phone: 662-508-5061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number14441
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number14441
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: