Provider Demographics
NPI:1760492185
Name:WILT, SHARON LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:SHARON
Middle Name:LYNN
Last Name:WILT
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 1:521 RIVER OVERLOOK
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:GA
Mailing Address - Zip Code:31029-4898
Mailing Address - Country:US
Mailing Address - Phone:601-942-0179
Mailing Address - Fax:
Practice Address - Street 1:2400 UNSER BLVD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124
Practice Address - Country:US
Practice Address - Phone:601-942-0179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA66842208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03075562Medicaid
GA003124060Medicaid