Provider Demographics
NPI:1275684730
Name:WILSON PODIATRY ASSOCIATES, PA
Entity type:Organization
Organization Name:WILSON PODIATRY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENDALL
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:252-237-0138
Mailing Address - Street 1:1704 GLENDALE DR SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4678
Mailing Address - Country:US
Mailing Address - Phone:252-237-0138
Mailing Address - Fax:252-237-7903
Practice Address - Street 1:1704 GLENDALE DR SW
Practice Address - Street 2:SUITE A
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4678
Practice Address - Country:US
Practice Address - Phone:252-237-0138
Practice Address - Fax:252-237-7903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC238213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty