MEDICARE: DR. LORI L WILSON DPM

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	171W00000X	Contractor	SC003555R	PA
2	213ES0131X	Foot Surgery Podiatrist	SC003555R	PA
3	261QP1100X	Podiatric Clinic/Center	SC003555R	PA
4	213ES0103X	Foot & Ankle Surgery Podiatrist	SC003555R	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679578249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LORI L WILSON DPM

Provider Business Mailing Address
First Line	:	104 DELAWARE AVE
Second Line	:	SUITE 246
City	:	UNIONTOWN
State	:	PA
Zip	:	15401-3100
Country	:	US
Telephone Number	:	724-439-1300
Fax Number	:	724-439-8727

Provider Business Practice Location Address
First Line	:	104 DELAWARE AVE
Second Line	:	SUITE 246
City	:	UNIONTOWN
State	:	PA
Zip	:	15401-3100
Country	:	US
Telephone Number	:	724-439-1300
Fax Number	:	724-439-8727

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	06/16/2018

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Directions to “ DR. LORI L WILSON DPM” Practice Location

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