Provider Demographics
NPI:1336223833
Name:WILSON, LISA ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:WILSON
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 1:3500 W PURDUE AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-6357
Mailing Address - Country:US
Mailing Address - Phone:765-747-6090
Mailing Address - Fax:765-747-5069
Practice Address - Street 1:3500 W PURDUE AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-6357
Practice Address - Country:US
Practice Address - Phone:765-747-6090
Practice Address - Fax:765-747-5069
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044182207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN202830BMedicare PIN
ING25199Medicare UPIN
OH4085841Medicare PIN