Provider Demographics
NPI:1710966510
Name:WILSON, JONATHAN P (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:P
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1985 STARTOWN RD.
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602
Mailing Address - Country:US
Mailing Address - Phone:828-327-4745
Mailing Address - Fax:828-327-0841
Practice Address - Street 1:1985 STARTOWN RD.
Practice Address - Street 2:FAIRBROCK MEDICAL CLINIC PA
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602
Practice Address - Country:US
Practice Address - Phone:828-327-4745
Practice Address - Fax:828-327-0841
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200500132207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2402446Medicare ID - Type Unspecified
NCI25591Medicare UPIN