Healthcare Provider Details

I. General information

NPI: 1699068445
Provider Name (Legal Business Name): SHAWN ANTHONY WILSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5838 HARBOUR VIEW BLVD BLDG STE 100
SUFFOLK VA
23435-2663
US

IV. Provider business mailing address

5838 HARBOUR VIEW BLVD BLDG STE 100
SUFFOLK VA
23435-2663
US

V. Phone/Fax

Practice location:
  • Phone: 757-673-5680
  • Fax: 757-483-3075
Mailing address:
  • Phone: 757-673-5680
  • Fax: 757-483-3075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0102205257
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: