Healthcare Provider Details

I. General information

NPI: 1619996121
Provider Name (Legal Business Name): SUZANNE LEE WILSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 10/02/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 PAGE ROAD
PINEHURST NC
28374-8798
US

IV. Provider business mailing address

205 PAGE ROAD
PINEHURST NC
28374-8798
US

V. Phone/Fax

Practice location:
  • Phone: 910-295-5511
  • Fax: 910-295-5481
Mailing address:
  • Phone: 910-295-5511
  • Fax: 910-295-5481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01975
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: