Provider Demographics
NPI:1548024169
Name:WILSON, LINDSAY
Entity type:Individual
Prefix:
First Name:LINDSAY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 ASHLEY RIVER RD APT 106
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-8000
Mailing Address - Country:US
Mailing Address - Phone:703-901-3278
Mailing Address - Fax:
Practice Address - Street 1:2040 ASHLEY RIVER RD APT 106
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-8000
Practice Address - Country:US
Practice Address - Phone:703-901-3278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0010196363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program