Provider Demographics
NPI:1437624236
Name:WILSON, SHANE DAVID (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:DAVID
Last Name:WILSON
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PARKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:FRAZIERS BOTTOM
Mailing Address - State:WV
Mailing Address - Zip Code:25082-6977
Mailing Address - Country:US
Mailing Address - Phone:304-382-1090
Mailing Address - Fax:
Practice Address - Street 1:1249 15TH ST STE 4000
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3663
Practice Address - Country:US
Practice Address - Phone:304-766-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV63040363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology