Healthcare Provider Details

I. General information

NPI: 1013849793
Provider Name (Legal Business Name): KATHERINE LYNN WILSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 MOREHEAD MEDICAL DR STE 600
CHARLOTTE NC
28204-2969
US

IV. Provider business mailing address

1025 MOREHEAD MEDICAL DR STE 600
CHARLOTTE NC
28204-2969
US

V. Phone/Fax

Practice location:
  • Phone: 704-355-6649
  • Fax: 704-446-4876
Mailing address:
  • Phone: 704-355-6649
  • Fax: 704-446-4876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-16617
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: