Provider Demographics
NPI:1063676690
Name:WILBOURN, RANCE BALLARD (MD)
Entity Type:Individual
Prefix:
First Name:RANCE
Middle Name:BALLARD
Last Name:WILBOURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 WEST ST STE 100
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3874
Mailing Address - Country:US
Mailing Address - Phone:901-440-8482
Mailing Address - Fax:901-440-8582
Practice Address - Street 1:2215 WEST ST STE 100
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138
Practice Address - Country:US
Practice Address - Phone:901-440-8482
Practice Address - Fax:901-440-8582
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS207662084N0400X
KYIP9582084N0400X
TN567372084N0400X
SC516792084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR230387001Medicaid
TNQ063676690Medicaid
MS04520877Medicaid