Basic Information
| Provider Information | |||||||||
| NPI: | 1134121221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1075 N FRASER ST | ||||||||
| Address2: | |||||||||
| City: | GEORGETOWN | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435274442 | ||||||||
| FaxNumber: | 8435274027 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 S MORGAN AVE | ||||||||
| Address2: | |||||||||
| City: | ANDREWS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432645253 | ||||||||
| FaxNumber: | 8432645970 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2005 | ||||||||
| LastUpdateDate: | 08/28/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD35689 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0101231693 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | TL32077 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5642205 | 05 | VA | MEDICAID |