Provider Demographics
NPI:1376579854
Name:WILSON, TINA (MD)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 HIGHWAY 45 BYP STE 604
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4403
Mailing Address - Country:US
Mailing Address - Phone:731-660-8781
Mailing Address - Fax:731-660-8739
Practice Address - Street 1:620 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301
Practice Address - Country:US
Practice Address - Phone:731-541-6067
Practice Address - Fax:731-541-3188
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN53942207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200851330Medicaid
IN260690HMedicare PIN
IN200851330Medicaid