1649233412 NPI number — LARA CORBETT WILSON MD

Table of content: LARA CORBETT WILSON MD (NPI 1649233412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649233412 NPI number — LARA CORBETT WILSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
LARA
Provider Middle Name:
CORBETT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CORBETT
Provider Other First Name:
LARA
Provider Other Middle Name:
LOU
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649233412
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
851 LEONARD FULGHUM BLVD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
MT PLEASANT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29464-3787
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-884-5133
Provider Business Mailing Address Fax Number:
843-849-3343

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
851 LEONARD FULGHUM BLVD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
MT PLEASANT
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29464-3787
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-884-5133
Provider Business Practice Location Address Fax Number:
843-849-3343
Provider Enumeration Date:
04/11/2006

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: 207V00000X , with the licence number:  20495 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: T42692 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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