=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801249669
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ANN WILSON AU.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2016
-----------------------------------------------------
Last Update Date | 05/18/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 161 RIVERSIDE DR
-----------------------------------------------------
City | BINGHAMTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13905-4176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-770-9050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 EDGEBROOK DR
-----------------------------------------------------
City | ROARING BROOK TWP
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18444-7644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-702-9365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | AT006464
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------