Provider Demographics
NPI:1902980196
Name:WILSON, LISA KAY (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:KAY
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-372-4000
Mailing Address - Fax:704-334-4855
Practice Address - Street 1:1718 E 4TH ST STE 907
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3282
Practice Address - Country:US
Practice Address - Phone:704-372-4000
Practice Address - Fax:704-334-4855
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24878207V00000X
NC2009-00533207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology