Individual
KELLY W WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
220 EAST HARRIS AVENUE, SAN ANGELO, TX 76903
(325) 658-1511
Mailing address
PO BOX 22000, SAN ANGELO, TX 76902-7200
(325) 658-1511
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
Primary
J0368
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
117722201
—
TX
Enumeration date
11/29/2005
Last updated
06/11/2018
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