Provider Demographics
NPI:1376564625
Name:WILSON MEDICAL GROUP, PLLC
Entity Type:Organization
Organization Name:WILSON MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRIE-ANNE
Authorized Official - Middle Name:ALEXANDRA
Authorized Official - Last Name:HERON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-237-5237
Mailing Address - Street 1:3302 NASH ST N
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27896-1232
Mailing Address - Country:US
Mailing Address - Phone:252-237-5237
Mailing Address - Fax:252-234-9932
Practice Address - Street 1:3302 NASH ST N
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-1232
Practice Address - Country:US
Practice Address - Phone:252-237-5237
Practice Address - Fax:252-234-9932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300353207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902803Medicaid
NC5902803Medicaid
NCH56254Medicare UPIN