Provider Demographics
NPI:1073581047
Name:WILSON, GINA G (FNP)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:G
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 PROFESSIONAL CT
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-2827
Mailing Address - Country:US
Mailing Address - Phone:803-433-7444
Mailing Address - Fax:803-433-7448
Practice Address - Street 1:1013 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-2827
Practice Address - Country:US
Practice Address - Phone:803-433-7444
Practice Address - Fax:803-433-7448
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN562363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCF39251Medicare UPIN