Provider Demographics
NPI:1942237862
Name:WILSON, LANCE B (MD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:B
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:777 TOWNSHIP LINE ROAD
Mailing Address - Street 2:STE. 200
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-5564
Mailing Address - Country:US
Mailing Address - Phone:215-860-0745
Mailing Address - Fax:215-860-7754
Practice Address - Street 1:777 TOWNSHIP LINE ROAD
Practice Address - Street 2:STE. 200
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-5564
Practice Address - Country:US
Practice Address - Phone:215-860-0775
Practice Address - Fax:215-860-7754
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2022-06-21
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Provider Licenses
StateLicense IDTaxonomies
PAMD029363E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016147740001Medicaid
C29247Medicare UPIN
PA081130Medicare PIN