Provider Demographics
NPI:1750761532
Name:WILSON, GRACE (MD)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1705 E BROADWAY STE 280
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-7185
Mailing Address - Country:US
Mailing Address - Phone:573-815-7119
Mailing Address - Fax:573-815-7116
Practice Address - Street 1:1705 E BROADWAY STE 280
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-7185
Practice Address - Country:US
Practice Address - Phone:573-815-7119
Practice Address - Fax:573-815-7116
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015017097207R00000X
MO2021030232207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine