Basic Information
| Provider Information | |||||||||
| NPI: | 1255701389 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MATHEWS | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1348 WALTON WAY | ||||||||
| Address2: | SUITE 5100 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309015104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067248611 | ||||||||
| FaxNumber: | 7067246202 | ||||||||
| Practice Location | |||||||||
| Address1: | 1348 WALTON WAY | ||||||||
| Address2: | SUITE 5100 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309015104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067248611 | ||||||||
| FaxNumber: | 7067245205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2015 | ||||||||
| LastUpdateDate: | 01/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 35399 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 007764 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.