Basic Information
| Provider Information | |||||||||
| NPI: | 1376579854 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | TINA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1804 HIGHWAY 45 BYP STE 604 | ||||||||
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| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383054403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316608781 | ||||||||
| FaxNumber: | 7316608739 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315416067 | ||||||||
| FaxNumber: | 7315413188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 10/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 53942 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.