Provider Demographics
NPI:1760205553
Name:WILE, LORAN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:LORAN
Middle Name:MARIE
Last Name:WILE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 SOUTH BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217
Mailing Address - Country:US
Mailing Address - Phone:704-525-6288
Mailing Address - Fax:704-525-6384
Practice Address - Street 1:4705 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217
Practice Address - Country:US
Practice Address - Phone:704-525-6288
Practice Address - Fax:704-525-6384
Is Sole Proprietor?:No
Enumeration Date:2024-11-01
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-14796202D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202D00000XAllopathic & Osteopathic PhysiciansIntegrative Medicine