Provider Demographics
NPI:1881066207
Name:WILSON, TATTIYONA
Entity type:Individual
Prefix:
First Name:TATTIYONA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3841 VAN NESS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-4062
Mailing Address - Country:US
Mailing Address - Phone:562-391-3981
Mailing Address - Fax:
Practice Address - Street 1:3841 VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081-4062
Practice Address - Country:US
Practice Address - Phone:562-391-3981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-25
Last Update Date:2015-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV00001935159Medicaid