Individual
SHANE CHARLES WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
118 E GRAND AVE, MEMPHIS, MO 63555-1419
(660) 465-7522
(660) 465-7526
Mailing address
118 E GRAND AVE, MEMPHIS, MO 63555-1419
(660) 465-7522
(660) 465-7526
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
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