Provider Demographics
NPI:1003884933
Name:WILSON, KATHLEEN ROSE (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ROSE
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 1:703 HILL COUNTRY DR
Mailing Address - Street 2:SUITE 302
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028-6162
Mailing Address - Country:US
Mailing Address - Phone:830-792-1132
Mailing Address - Fax:830-792-7747
Practice Address - Street 1:703 HILL COUNTRY DR
Practice Address - Street 2:SUITE 302
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-6162
Practice Address - Country:US
Practice Address - Phone:830-792-1132
Practice Address - Fax:830-792-7747
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8230207R00000X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0084575OtherBLUE CROSS BLUE LINK #
TX1702987-01Medicaid
TX8K7450OtherBLUE CROSS PROVIDER #
TX8K7450OtherBLUE CROSS PROVIDER #
TX0084575OtherBLUE CROSS BLUE LINK #
TXH99540Medicare UPIN