Provider Demographics
NPI:1477808467
Name:WILSON, SHANE CHARLES (DO)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:CHARLES
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:450 E SIGLER AVE
Mailing Address - Street 2:STE A
Mailing Address - City:MEMPHIS
Mailing Address - State:MO
Mailing Address - Zip Code:63555-1726
Mailing Address - Country:US
Mailing Address - Phone:660-465-2828
Mailing Address - Fax:660-465-2956
Practice Address - Street 1:450 E SIGLER AVE
Practice Address - Street 2:STE A
Practice Address - City:MEMPHIS
Practice Address - State:MO
Practice Address - Zip Code:63555-1726
Practice Address - Country:US
Practice Address - Phone:660-465-2828
Practice Address - Fax:660-465-2956
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2014026613207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1477808467Medicaid