Basic Information
| Provider Information | |||||||||
| NPI: | 1073247847 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LATRESIA A. WILSON, MD, PA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26040 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312216040 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3330 NW 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344752652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784751299 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2022 | ||||||||
| LastUpdateDate: | 07/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | LATRESIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4784751299 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.