Provider Demographics
NPI:1649241613
Name:WILSON, LATRESIA ANN (MD)
Entity Type:Individual
Prefix:
First Name:LATRESIA
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
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 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-265-5911
Mailing Address - Fax:352-265-5606
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-5911
Practice Address - Fax:352-265-5606
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0087826207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267598600Medicaid
81081NMedicare PIN
H93497Medicare UPIN
81081QMedicare PIN
FL81081MMedicare PIN