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General NPI Number Information
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NPI Number | 1306848981
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Entity Type | Individual
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Provider Name | LARRY DON WILSON PA-C
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Gender | Male
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Dates
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Enumeration Date | 08/12/2005
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Last Update Date | 12/21/2010
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Provider Practice Location Address
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Address Line | 1136 GRAND AVE
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City | BACLIFF
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State | TX
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Zip | 77518-2760
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Country | US
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Telephone | 281-339-5018
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Fax | 281-339-5098
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Provider Business Mailing Address
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Address Line | 2826 FOREST HILLS DR
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City | LEAGUE CITY
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State | TX
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Zip | 77573-5750
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Country | US
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Telephone | 281-334-6328
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Fax | 281-538-1715
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA00742
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License Number State | TX
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