Individual
SHANE CHARLES WILSON
Active
Individual
SHANE CHARLES WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
2014026613
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1477808467
—
MO
05
—
200022529
—
MO
Enumeration date
07/17/2012
Last updated
05/08/2026
Update your record
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