Provider Demographics
NPI:1043718471
Name:WILSON, LISA
Entity type:Individual
Prefix:
First Name:LISA
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 1:950 INDIAN TRAIL LILBURN RD NW STE 5D
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-6870
Mailing Address - Country:US
Mailing Address - Phone:470-545-2131
Mailing Address - Fax:
Practice Address - Street 1:950 INDIAN TRAIL LILBURN RD NW STE 5D
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-6870
Practice Address - Country:US
Practice Address - Phone:470-545-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA581242085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA58124OtherREGISTRY