Provider Demographics
NPI:1346917978
Name:WILSON, CASEY (APN)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 BEECH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:HARROGATE
Mailing Address - State:TN
Mailing Address - Zip Code:37752-8251
Mailing Address - Country:US
Mailing Address - Phone:865-579-6756
Mailing Address - Fax:
Practice Address - Street 1:170 BEECH ST STE 1
Practice Address - Street 2:
Practice Address - City:HARROGATE
Practice Address - State:TN
Practice Address - Zip Code:37752-8251
Practice Address - Country:US
Practice Address - Phone:865-579-6756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN30119363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner