Provider Demographics
NPI:1003841354
Name:WILSON, JAMES KEENAN (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:KEENAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MS
Mailing Address - Zip Code:38967-1901
Mailing Address - Country:US
Mailing Address - Phone:662-508-5061
Mailing Address - Fax:
Practice Address - Street 1:500 VETERANS MEMORIAL BLVD S
Practice Address - Street 2:
Practice Address - City:EUPORA
Practice Address - State:MS
Practice Address - Zip Code:39744-2215
Practice Address - Country:US
Practice Address - Phone:662-258-6221
Practice Address - Fax:662-258-9291
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14441207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0113851Medicaid
F85487Medicare UPIN