Provider Demographics
NPI:1356458517
Name:WILSON, SHAWN P (MD)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:P
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1446 N RANDALL AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-1122
Mailing Address - Country:US
Mailing Address - Phone:608-758-7215
Mailing Address - Fax:608-758-3216
Practice Address - Street 1:1969 W HART RD
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511
Practice Address - Country:US
Practice Address - Phone:608-758-7215
Practice Address - Fax:608-758-3216
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI031093207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31583400Medicaid
E06629Medicare UPIN
WI000454170Medicare ID - Type Unspecified