Basic Information
| Provider Information | |||||||||
| NPI: | 1699068445 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5838 HARBOUR VIEW BLVD BLDG STE 100 | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234352663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576735680 | ||||||||
| FaxNumber: | 7574833075 | ||||||||
| Practice Location | |||||||||
| Address1: | 5838 HARBOUR VIEW BLVD BLDG STE 100 | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234352663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576735680 | ||||||||
| FaxNumber: | 7574833075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2011 | ||||||||
| LastUpdateDate: | 09/24/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 0102205257 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.