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General NPI Number Information
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NPI Number | 1790756542
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Entity Type | Individual
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Provider Name | JACK EDWARD WILSON MD
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Gender | Male
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Dates
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Enumeration Date | 01/30/2006
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Last Update Date | 01/23/2021
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Provider Practice Location Address
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Address Line | 3 WALNUT ST STE 100
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City | LEMOYNE
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State | PA
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Zip | 17043
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Country | US
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Telephone | 717-761-4141
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Fax | 717-761-1456
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Provider Business Mailing Address
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Address Line | 409 S 2ND ST SUITE 2F
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City | HARRISBURG
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State | PA
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Zip | 17104-1612
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Country | US
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Telephone |
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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 | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | MD025597E
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License Number State | PA
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