Provider Demographics
NPI:1760149991
Name:WILSON, CORA (PA-C)
Entity Type:Individual
Prefix:
First Name:CORA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1679 OKALONA RD
Mailing Address - Street 2:
Mailing Address - City:RICKMAN
Mailing Address - State:TN
Mailing Address - Zip Code:38580-1957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8401 HWY 111
Practice Address - Street 2:
Practice Address - City:BYRDSTOWN
Practice Address - State:TN
Practice Address - Zip Code:38549-1006
Practice Address - Country:US
Practice Address - Phone:931-864-3187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-22
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4795363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant