=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407965445
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEONARD C WILSON PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2495 SHREVEPORT HWY BLDG 9
-----------------------------------------------------
City | PINEVILLE
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71360-4044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-473-0010
-----------------------------------------------------
Fax | 318-483-5036
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 69004
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71306-9004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-473-0010
-----------------------------------------------------
Fax | 318-483-5036
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | NA
-----------------------------------------------------
License Number State |
-----------------------------------------------------