Healthcare Provider Details

I. General information

NPI: 1639142185
Provider Name (Legal Business Name): NANCY L WILSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 W 69TH ST STE 1500
SIOUX FALLS SD
57108-8170
US

IV. Provider business mailing address

2400 S. MINNESOTA AVE STE 100
SIOUX FALLS SD
57105-3762
US

V. Phone/Fax

Practice location:
  • Phone: 605-322-5700
  • Fax: 605-322-5704
Mailing address:
  • Phone: 605-322-7510
  • Fax: 605-322-6475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1225
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: