Provider Demographics
NPI:1639229040
Name:WILSON, LAWRENCE WOODROW (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:WOODROW
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:5701 BALLOON FIESTA PARKWAY
Mailing Address - Street 2:CARE OF BLUE CROSS BLUE SHIELD OF NEW MEXICO
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113
Mailing Address - Country:US
Mailing Address - Phone:505-816-2093
Mailing Address - Fax:505-816-3608
Practice Address - Street 1:5701 BALLOON FIESTA PARKWAY
Practice Address - Street 2:CARE OF BLUE CROSS BLUE SHIELD OF NEW MEXICO
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113
Practice Address - Country:US
Practice Address - Phone:505-816-2093
Practice Address - Fax:505-816-3608
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NM99-332207Q00000X
ND4269207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine