Provider Demographics
NPI:1649546490
Name:WILSON, KIMBERLY NICOLE GOSS (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:NICOLE GOSS
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 1:2502 W SAINT ISABEL ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2502 W SAINT ISABEL ST
Practice Address - Street 2:SUITE B
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6370
Practice Address - Country:US
Practice Address - Phone:813-874-5707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-27
Last Update Date:2015-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME119165207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program