Basic Information
| Provider Information | |||||||||
| NPI: | 1417208810 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | PHOEBE | ||||||||
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| NamePrefix: | MRS. | ||||||||
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| Credential: | PNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1952 LONG GROVE DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | MT PLEASANT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294647579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437958100 | ||||||||
| FaxNumber: | 8435732534 | ||||||||
| Practice Location | |||||||||
| Address1: | 776 DANIEL ELLIS DR | ||||||||
| Address2: | SUITE 2 BUILDING A | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294123094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437958100 | ||||||||
| FaxNumber: | 8435732534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2012 | ||||||||
| LastUpdateDate: | 10/08/2014 | ||||||||
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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 | 363LP0200X | 18030 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.