Provider Demographics
NPI:1366485443
Name:WILSON, THOMAS A (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:WILSON
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 1:339 WILDLIFE RD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27332-0846
Mailing Address - Country:US
Mailing Address - Phone:336-267-1186
Mailing Address - Fax:877-472-2302
Practice Address - Street 1:778 HOFFMAN RD
Practice Address - Street 2:
Practice Address - City:WEST END
Practice Address - State:NC
Practice Address - Zip Code:27376-9029
Practice Address - Country:US
Practice Address - Phone:877-472-2302
Practice Address - Fax:877-472-2302
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC194272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8988468Medicaid
NC8988468Medicaid
NC2069834Medicare PIN