Healthcare Provider Details

I. General information

NPI: 1467988014
Provider Name (Legal Business Name): ADAM KENNETH WILLSON M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 BARRETT DR STE 300
RALEIGH NC
27609-7172
US

IV. Provider business mailing address

PO BOX 18563
RALEIGH NC
27619-8563
US

V. Phone/Fax

Practice location:
  • Phone: 919-782-1806
  • Fax: 919-782-4756
Mailing address:
  • Phone: 919-782-1806
  • Fax: 919-782-4756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2021-00765
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2021-00765
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: