Individual
MR. KENT SHANNON WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2080 WOODWINDS DRIVE, #120, WOODBURY, MN 55125
(651) 702-0750
(651) 702-0749
Mailing address
2080 WOODWINDS DRIVE, #120, WOODBURY, MN 55125
(651) 702-0750
(651) 645-6166
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
Primary
17805
MN
208600000X
Surgery Physician
17805
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
905070100
—
MN
Enumeration date
06/22/2006
Last updated
12/04/2009
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