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General NPI Number Information
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NPI Number | 1780758094
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Entity Type | Individual
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Provider Name | ROBERT WAYNE WILSON MD
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Gender | Male
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Dates
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Enumeration Date | 11/20/2006
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Last Update Date | 05/25/2017
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Provider Practice Location Address
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Address Line | 700 SE 3RD AVE
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City | FORT LAUDERDALE
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State | FL
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Zip | 33316-1139
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Country | US
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Telephone | 954-522-3132
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Fax |
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Provider Business Mailing Address
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Address Line | 147 OLDE POINT ROAD
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City | HMPSTEAD
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State | NC
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Zip | 28443
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Country | US
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Telephone | 910-512-4434
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Fax |
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 31696
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | ME113477
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License Number State | FL
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