Provider Demographics
NPI:1689638892
Name:WILSON, LISA MICHELLE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
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 561
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-0561
Mailing Address - Country:US
Mailing Address - Phone:336-322-1024
Mailing Address - Fax:336-322-1022
Practice Address - Street 1:3762 DURHAM RD
Practice Address - Street 2:SUITE B
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-2741
Practice Address - Country:US
Practice Address - Phone:336-322-1024
Practice Address - Fax:336-322-1022
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200201023207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903537Medicaid
SCN0102AMedicaid
NCI37590Medicare UPIN
NC5903537Medicaid