Basic Information
| Provider Information | |||||||||
| NPI: | 1437624236 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | SHANE | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | AGACNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 PARKSTONE DR | ||||||||
| Address2: | |||||||||
| City: | FRAZIERS BOTTOM | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250826977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043821090 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1249 15TH ST STE 4000 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047663600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2018 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 63040 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2100X | 63040 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.