Individual
DR. LARRY T WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
701 S MORGAN AVE, ANDREWS, SC 29510
(843) 264-5253
(843) 264-5970
Mailing address
1075 N FRASER ST, GEORGETOWN, SC 29440
(843) 527-4442
(843) 527-4027
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
0101231693
VA
207Q00000X
Family Medicine Physician
MD35689
TN
207Q00000X
Family Medicine Physician
Primary
TL32077
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
5642205
—
VA
Enumeration date
06/02/2005
Last updated
08/28/2009
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