Basic Information
| Provider Information | |||||||||
| NPI: | 1053384859 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TST MEDICAL, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2448 | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287932448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286934431 | ||||||||
| FaxNumber: | 8286934871 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 BALSAM RD | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287925703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286934431 | ||||||||
| FaxNumber: | 8286934871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 08/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | BRANDY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8286934431 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 89013NW | 05 | NC | MEDICAID |