Basic Information
| Provider Information | |||||||||
| NPI: | 1538438452 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | LEWIS | ||||||||
| MiddleName: | CODY BUCK | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | AA CERTIFIED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1984 PEACHTREE RD NW | ||||||||
| Address2: | 515 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303095219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043511745 | ||||||||
| FaxNumber: | 4043517121 | ||||||||
| Practice Location | |||||||||
| Address1: | 1984 PEACHTREE RD NW | ||||||||
| Address2: | 515 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303095219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043511745 | ||||||||
| FaxNumber: | 4043517121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2011 | ||||||||
| LastUpdateDate: | 09/14/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 2327 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.