Provider Demographics
NPI:1205002227
Name:WILSON, BRAD P (DO)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:P
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 NEW SHACKLE ISLAND RD STE 148C
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-2366
Mailing Address - Country:US
Mailing Address - Phone:615-972-1100
Mailing Address - Fax:615-537-4950
Practice Address - Street 1:353 NEW SHACKLE ISLAND RD STE 148C
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2366
Practice Address - Country:US
Practice Address - Phone:615-972-1100
Practice Address - Fax:615-537-4950
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO0000002339208VP0014X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1531353Medicaid