Provider Demographics
NPI:1023399896
Name:WILSON, LISA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 82ND PKWY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4607
Mailing Address - Country:US
Mailing Address - Phone:843-692-1752
Mailing Address - Fax:
Practice Address - Street 1:809 82ND PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4607
Practice Address - Country:US
Practice Address - Phone:843-497-5929
Practice Address - Fax:843-497-6601
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1687363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1249PAMedicaid
SC1687OtherSTATE LICENSE