Basic Information
| Provider Information | |||||||||
| NPI: | 1295716967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POWERS | ||||||||
| FirstName: | WILSON | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1275 DICK LONAS RD UNIT 101 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379091383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655844747 | ||||||||
| FaxNumber: | 8655841363 | ||||||||
| Practice Location | |||||||||
| Address1: | 11021 CHAPMAN HWY | ||||||||
| Address2: | |||||||||
| City: | SEYMOUR | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655793720 | ||||||||
| FaxNumber: | 8655777309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 12/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/19/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD0000011676 | TN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | Q007781 | 05 | TN | MEDICAID |