Individual
SHANE DAVID WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
AGACNP-BC
Contact information
Practice address
1249 15TH ST STE 4000, HUNTINGTON, WV 25701-3663
(304) 766-3600
Mailing address
201 PARKSTONE DR, FRAZIERS BOTTOM, WV 25082-6977
(304) 382-1090
Taxonomy
Speciality
Code
Description
License number
State
363LA2100X
Acute Care Nurse Practitioner
Primary
63040
WV
363LG0600X
Gerontology Nurse Practitioner
63040
WV
Other
Enumeration date
10/08/2018
Last updated
10/30/2020
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