Individual
LARRY DON WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1136 GRAND AVE, BACLIFF, TX 77518-2760
(281) 339-5018
(281) 339-5098
Mailing address
2826 FOREST HILLS DR, LEAGUE CITY, TX 77573-5750
(281) 334-6328
(281) 538-1715
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA00742
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PA00742
STATE LICENSE
TX
Enumeration date
08/12/2005
Last updated
12/21/2010
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