Provider Demographics
NPI:1376870188
Name:WILSON, SHARON (LO)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LO
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 262
Mailing Address - Street 2:
Mailing Address - City:WEST
Mailing Address - State:TX
Mailing Address - Zip Code:76691-0262
Mailing Address - Country:US
Mailing Address - Phone:254-826-5178
Mailing Address - Fax:
Practice Address - Street 1:801 S HARRISON ST
Practice Address - Street 2:
Practice Address - City:WEST
Practice Address - State:TX
Practice Address - Zip Code:76691-1727
Practice Address - Country:US
Practice Address - Phone:254-826-5178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-16
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX342174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist