Provider Demographics
NPI:1043847676
Name:WILSON, TATIANA A
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TATIANA
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1805 S SANTA FE AVE
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74003-6140
Mailing Address - Country:US
Mailing Address - Phone:918-440-7506
Mailing Address - Fax:
Practice Address - Street 1:504 S CHEROKEE AVE
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74003-3625
Practice Address - Country:US
Practice Address - Phone:918-876-4046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKW2K08233825WOtherBLUECROSS BLUESHIELD