Healthcare Provider Details

I. General information

NPI: 1801425558
Provider Name (Legal Business Name): EVERETT WILSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2020
Last Update Date: 09/13/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10226 COULOAK DR STE 100
CHARLOTTE NC
28216-7688
US

IV. Provider business mailing address

10226 COULOAK DR STE 100
CHARLOTTE NC
28216-7688
US

V. Phone/Fax

Practice location:
  • Phone: 704-801-7380
  • Fax:
Mailing address:
  • Phone: 704-801-7380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2025-01739
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: