Provider Demographics
NPI:1083681423
Name:WILSON, WAYNE VINCENT (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:VINCENT
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:PO BOX 6115
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28603-6115
Mailing Address - Country:US
Mailing Address - Phone:828-495-4445
Mailing Address - Fax:828-495-4449
Practice Address - Street 1:1232 SHILOH CHURCH RD
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-7856
Practice Address - Country:US
Practice Address - Phone:828-495-4445
Practice Address - Fax:828-495-4449
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-03
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8988499Medicaid
NCF60352Medicare UPIN
NC8988499Medicaid