1255701389 NPI number — MS. LAUREN ELIZABETH WILSON PA-C

Table of content: MS. LAUREN ELIZABETH WILSON PA-C (NPI 1255701389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255701389 NPI number — MS. LAUREN ELIZABETH WILSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
LAUREN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MATHEWS
Provider Other First Name:
LAUREN
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255701389
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1348 WALTON WAY
Provider Second Line Business Mailing Address:
SUITE 5100
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30901-5104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-724-8611
Provider Business Mailing Address Fax Number:
706-724-6202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1348 WALTON WAY
Provider Second Line Business Practice Location Address:
SUITE 5100
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30901-5104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-724-8611
Provider Business Practice Location Address Fax Number:
706-724-5205
Provider Enumeration Date:
10/01/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  007764 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X , with the licence number: 35399 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)