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General NPI Number Information
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NPI Number | 1336271733
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Entity Type | Individual
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Provider Name | MARTHA L WILSON M.D.
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Gender | Female
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Dates
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Enumeration Date | 03/12/2007
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 104 E STUART DR
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City | GALAX
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State | VA
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Zip | 24333-2119
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Country | US
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Telephone | 276-238-9902
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Fax | 276-238-9907
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Provider Business Mailing Address
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Address Line | 104 E STUART DR
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City | GALAX
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State | VA
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Zip | 24333-2119
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Country | US
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Telephone | 276-238-9902
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Fax | 276-238-9907
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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 | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 0101230418
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | ME0042356
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | 0101230418
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License Number State | VA
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Taxonomy #4
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Taxonomy Code | 207NP0225X
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Taxonomy Name | Pediatric Dermatology Physician
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License Number | 0101230418
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License Number State | VA
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Taxonomy #5
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Taxonomy Code | 207NS0135X
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Taxonomy Name | Procedural Dermatology Physician
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License Number | 0101230418
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License Number State | VA
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