Healthcare Provider Details

I. General information

NPI: 1003044694
Provider Name (Legal Business Name): LINDSAY R WILSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 PETERS CREEK RD NW
ROANOKE VA
24017-2500
US

IV. Provider business mailing address

1314 PETERS CREEK RD NW
ROANOKE VA
24017-2500
US

V. Phone/Fax

Practice location:
  • Phone: 540-562-5703
  • Fax: 540-562-4278
Mailing address:
  • Phone: 540-562-5703
  • Fax: 540-562-4278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number0102203035
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number0102203035
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102203035
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: