Provider Demographics
NPI:1861450983
Name:WILSON, LORETTA K (ANP)
Entity Type:Individual
Prefix:MS
First Name:LORETTA
Middle Name:K
Last Name:WILSON
Suffix:
Gender:F
Credentials:ANP
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 602658
Mailing Address - Street 2:WAKE FOREST UNIVERSITY HEALTH SCIENCES
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2658
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-3202
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC900352363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1861450983OtherPARTNERS
SCQNP211OtherSC MEDICAID
NC1861450983OtherVIRGINIA MEDICAID
NC3648339OtherUNITED HEALTHCARE
NCP00654521OtherRAILROAD MEDICARE
NC1761XOtherBCBS
NC1861450983OtherTRICARE
NC268270OtherMEDCOST
NC4744420OtherAETNA
NC1761XOtherBCBS
NCP83148Medicare UPIN
SCQNP211OtherSC MEDICAID
NC2807786AMedicare ID - Type Unspecified
NC1861450983OtherPARTNERS