Healthcare Provider Details

I. General information

NPI: 1639571011
Provider Name (Legal Business Name): JOSHUA WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2014
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 MEMORIAL DR
PINEHURST NC
28374-8710
US

IV. Provider business mailing address

PO BOX 8500
PINEHURST NC
28374-8500
US

V. Phone/Fax

Practice location:
  • Phone: 910-715-1233
  • Fax: 910-715-1943
Mailing address:
  • Phone: 910-715-1233
  • Fax: 910-715-1943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: