Provider Demographics
NPI:1679578249
Name:WILSON, LORI L (DPM)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 DELAWARE AVE
Mailing Address - Street 2:SUITE 246
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-3100
Mailing Address - Country:US
Mailing Address - Phone:724-439-1300
Mailing Address - Fax:724-439-8727
Practice Address - Street 1:104 DELAWARE AVE
Practice Address - Street 2:SUITE 246
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-3100
Practice Address - Country:US
Practice Address - Phone:724-439-1300
Practice Address - Fax:724-439-8727
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003555R171W00000X, 213ES0131X, 261QP1100X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No171W00000XOther Service ProvidersContractor
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001214510003Medicaid
PAU16801Medicare UPIN
PA0012174510001Medicaid