Provider Demographics
NPI:1407035629
Name:WILSON, MISTI H (MD)
Entity Type:Individual
Prefix:
First Name:MISTI
Middle Name:H
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:601 WATKINS CENTRE PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-0002
Mailing Address - Country:US
Mailing Address - Phone:804-594-3130
Mailing Address - Fax:804-423-6517
Practice Address - Street 1:601 WATKINS CENTRE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-0002
Practice Address - Country:US
Practice Address - Phone:804-594-3130
Practice Address - Fax:804-423-6517
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARE-70472086X0206X
VA0101254102208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09633OtherGROUP PTAN