Provider Demographics
NPI:1457854564
Name:WILSON, TAMERA BURTON
Entity Type:Individual
Prefix:
First Name:TAMERA
Middle Name:BURTON
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 VILLAGE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN INN
Mailing Address - State:SC
Mailing Address - Zip Code:29644-1347
Mailing Address - Country:US
Mailing Address - Phone:336-213-0975
Mailing Address - Fax:
Practice Address - Street 1:123 VILLAGE VISTA DR
Practice Address - Street 2:
Practice Address - City:FOUNTAIN INN
Practice Address - State:SC
Practice Address - Zip Code:29644-1347
Practice Address - Country:US
Practice Address - Phone:336-213-0975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management