Provider Demographics
NPI:1629677182
Name:WILSON, TAHIRA (RN)
Entity Type:Individual
Prefix:
First Name:TAHIRA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 KEITH RD UNIT 9
Mailing Address - Street 2:
Mailing Address - City:ABINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19001-2628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1521 66TH AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19126-2766
Practice Address - Country:US
Practice Address - Phone:215-237-6439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-25
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No385H00000XRespite Care FacilityRespite Care
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No251G00000XAgenciesHospice Care, Community Based
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1038259300001Medicaid