Basic Information
| Provider Information | |||||||||
| NPI: | 1598931370 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | ELLEN | ||||||||
| MiddleName: | ROSSER | ||||||||
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| Credential: | AUD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1915 K M WICKER MEMORIAL DR | ||||||||
| Address2: | CENTRAL CAROLINA ENT ASSOCIATES | ||||||||
| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273305070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197746829 | ||||||||
| FaxNumber: | 9197752327 | ||||||||
| Practice Location | |||||||||
| Address1: | 1915 K M WICKER MEMORIAL DR | ||||||||
| Address2: | CENTRAL CAROLINA ENT ASSOCIATES | ||||||||
| City: | SANFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273305070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197746829 | ||||||||
| FaxNumber: | 9197752327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2008 | ||||||||
| LastUpdateDate: | 09/15/2009 | ||||||||
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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 | 231H00000X | 2126 | NC | Y | Speech, Language and Hearing Service Providers | Audiologist | 237700000X | 588 | NC | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 890107W | 05 | NC | MEDICAID | 2126 | 01 | AUDIOLOGIST LICENSE # | OTHER | 3404108 | 01 | NC | MEDICAID HEARING AID VENDOR | OTHER |