Provider Demographics
NPI:1114936069
Name:NICHOLSON-WILSON, MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:NICHOLSON-WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:N
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:60 COMMERCE DRIVE
Mailing Address - Street 2:P O BOX 1659
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-1659
Mailing Address - Country:US
Mailing Address - Phone:910-521-2900
Mailing Address - Fax:910-272-1654
Practice Address - Street 1:610 E DR MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:MAXTON
Practice Address - State:NC
Practice Address - Zip Code:28364-1800
Practice Address - Country:US
Practice Address - Phone:910-844-5410
Practice Address - Fax:910-844-3290
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC94-00955207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7988330 89015A5Medicaid
NCF70498Medicare UPIN
NC7988330 89015A5Medicaid