Provider Demographics
NPI:1003044694
Name:WILSON, LINDSAY R (DO)
Entity Type:Individual
Prefix:
First Name:LINDSAY
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 PETERS CREEK RD NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24017-2500
Mailing Address - Country:US
Mailing Address - Phone:540-562-5703
Mailing Address - Fax:540-562-4278
Practice Address - Street 1:1314 PETERS CREEK RD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-2500
Practice Address - Country:US
Practice Address - Phone:540-562-5703
Practice Address - Fax:540-562-4278
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102203035207QH0002X, 208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVA989BMedicare PIN