1952502544 NPI number — DR. SHAWN L WILLSON MD

Table of content: DR. SHAWN L WILLSON MD (NPI 1952502544)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952502544 NPI number — DR. SHAWN L WILLSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLSON
Provider First Name:
SHAWN
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952502544
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
840 FLEMING ST STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSONVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28791-3541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-948-1340
Provider Business Mailing Address Fax Number:
828-595-9499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
840 FLEMING ST STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSONVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28791-3541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-948-1340
Provider Business Practice Location Address Fax Number:
828-595-9499
Provider Enumeration Date:
05/30/2007

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: 2084N0400X , with the licence number:  DR.0036177 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 2017-01998 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1952502544 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200599170A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".