Basic Information
| Provider Information | |||||||||
| NPI: | 1518951342 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4214 ANDREWS HWY STE 240 | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797034817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4326866605 | ||||||||
| FaxNumber: | 4326822284 | ||||||||
| Practice Location | |||||||||
| Address1: | 2012 W OHIO AVE | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797015946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4322213200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 03/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | K4609 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | K4609 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 042980504 | 05 | TX | MEDICAID | 1L5835 | 01 | TX | TX MEDICARE-PREMIER | OTHER | 1L5486 | 01 | TX | TX MEDICARE-MIMA | OTHER |