Basic Information
| Provider Information | |||||||||
| NPI: | 1467988014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLSON | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | KENNETH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18563 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276198563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197821806 | ||||||||
| FaxNumber: | 9197824756 | ||||||||
| Practice Location | |||||||||
| Address1: | 3521 HAWORTH DR | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276097244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197821806 | ||||||||
| FaxNumber: | 9197824756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2017 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 2021-00765 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.