MEDICARE: WILSON DERMATOLOGY CLINIC PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1174589345
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILSON DERMATOLOGY CLINIC PA

Provider Business Mailing Address
First Line	:	2874 WARD BLVD
Second Line	:
City	:	WILSON
State	:	NC
Zip	:	27893-1761
Country	:	US
Telephone Number	:	252-291-5600
Fax Number	:	252-291-6935

Provider Business Practice Location Address
First Line	:	2874 WARD BLVD
Second Line	:
City	:	WILSON
State	:	NC
Zip	:	27893-1761
Country	:	US
Telephone Number	:	252-291-5600
Fax Number	:	252-291-6935

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAVID W CORBETT
Credential	:	DO
Telephone Number	:	252-291-5600

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	08/22/2020

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1982537742 — MS. TORRASA TE-ANDRE' BARNES
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