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General NPI Number Information
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NPI Number | 1497141311
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Entity Type | Organization
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Legal Business Name | PELICAN STATE FOOT & ANKLE CARE LLC
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Dates
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Enumeration Date | 04/07/2015
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Last Update Date | 07/23/2015
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Provider Practice Location Address
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Address Line | 1938 JACKSON ST
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City | ALEXANDRIA
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State | LA
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Zip | 71301-6437
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Country | US
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Telephone | 985-867-0301
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1228
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City | ALEXANDRIA
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State | LA
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Zip | 71309-1228
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Country | US
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Telephone | 985-867-0301
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JON M WILSON JR.
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Credential | DPM
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Telephone | 985-867-0301
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | DPM.200036
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License Number State | LA
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