Provider Demographics
NPI:1053313957
Name:WILSON, EDWINA C (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWINA
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 BUFFALO ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-1111
Mailing Address - Country:US
Mailing Address - Phone:434-392-8177
Mailing Address - Fax:434-392-8272
Practice Address - Street 1:833 BUFFALO ST
Practice Address - Street 2:SUITE 200
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-1111
Practice Address - Country:US
Practice Address - Phone:434-392-8177
Practice Address - Fax:434-392-8272
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045725207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900615Medicaid
NC88245OtherBLUE CROSS BLUE SHIELD
NC2172170CMedicare ID - Type UnspecifiedMEDICARE
NCF29768Medicare UPIN