Provider Demographics
NPI:1952502544
Name:WILLSON, SHAWN L (MD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:L
Last Name:WILLSON
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 1:840 FLEMING ST STE 3
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28791-3541
Mailing Address - Country:US
Mailing Address - Phone:913-948-1340
Mailing Address - Fax:828-595-9499
Practice Address - Street 1:840 FLEMING ST STE 3
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28791-3541
Practice Address - Country:US
Practice Address - Phone:913-948-1340
Practice Address - Fax:828-595-9499
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00361772084N0400X
NC2017-019982084N0400X
KS04335742084F0202X, 2084A0401X
MO20090020572084F0202X
MO200900200572084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1952502544Medicaid
KS200599170AMedicaid
KS200599170AMedicaid
KS395000001Medicare PIN
MO1952502544Medicaid