Provider Demographics
NPI:1922063247
Name:WILSON, PATRICIA J (CNM)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E SPRINGBROOK DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1761
Mailing Address - Country:US
Mailing Address - Phone:423-530-7900
Mailing Address - Fax:423-530-7901
Practice Address - Street 1:2002 BROOKSIDE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4634
Practice Address - Country:US
Practice Address - Phone:423-392-6370
Practice Address - Fax:423-392-6081
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN78573363LW0102X
TN12895363LW0102X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1532284Medicaid
VA1922063247Medicaid
VA1922063247Medicaid
TN3042160OtherBCBS
S76371Medicare UPIN
TN1532284Medicaid