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General NPI Number Information
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NPI Number | 1720393937
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Entity Type | Organization
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Legal Business Name | CHARLES A. WILSON D.O., LLC
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Dates
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Enumeration Date | 08/11/2010
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Last Update Date | 08/11/2010
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Provider Practice Location Address
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Address Line | 91-2139 FORT WEAVER RD SUITE 213
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City | EWA BEACH
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State | HI
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Zip | 96706-3607
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Country | US
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Telephone | 808-677-8008
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Fax | 808-677-8007
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Provider Business Mailing Address
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Address Line | 91-2139 FORT WEAVER RD SUITE 213
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City | EWA BEACH
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State | HI
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Zip | 96706-3607
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Country | US
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Telephone | 808-677-8008
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Fax | 808-677-8007
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | DR. CHARLES ASHLEY WILSON
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Credential | D.O.
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Telephone | 808-744-1906
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | DOS 1154
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License Number State | HI
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