Basic Information
| Provider Information | |||||||||
| NPI: | 1598824682 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 623 E BROAD ST | ||||||||
| Address2: | 2ND FLR | ||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180186332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109546048 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 OSTRUM ST | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180151000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109544000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 07/26/2007 | ||||||||
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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 | 363A00000X | MA001584L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.