Provider Demographics
NPI:1902818461
Name:WILSON, JOHN LEIGHTON JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LEIGHTON
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1312 PATTON AVE
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28806-2604
Mailing Address - Country:US
Mailing Address - Phone:828-252-9833
Mailing Address - Fax:828-255-8118
Practice Address - Street 1:1312 PATTON AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806-2604
Practice Address - Country:US
Practice Address - Phone:828-252-9833
Practice Address - Fax:828-255-8118
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34207174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164526Medicare ID - Type Unspecified
D80146Medicare UPIN