Provider Demographics
NPI:1124013198
Name:WILKINSON MOORE, TINA ANN (PA)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:ANN
Last Name:WILKINSON MOORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 E I 20 SERVICE RD S
Mailing Address - Street 2:
Mailing Address - City:WILLOW PARK
Mailing Address - State:TX
Mailing Address - Zip Code:76008-5115
Mailing Address - Country:US
Mailing Address - Phone:817-737-7000
Mailing Address - Fax:
Practice Address - Street 1:5700 E I 20 SERVICE RD S
Practice Address - Street 2:
Practice Address - City:WILLOW PARK
Practice Address - State:TX
Practice Address - Zip Code:76008-5115
Practice Address - Country:US
Practice Address - Phone:817-489-7300
Practice Address - Fax:817-489-7302
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03112363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX196341501Medicaid
TX196341502Medicaid
TX8F9743OtherBCBS
TXTXB108085Medicare PIN
TX8K7281Medicare PIN