Basic Information
| Provider Information | |||||||||
| NPI: | 1639533953 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | APN, NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3960 NEW COVINGTON PIKE | ||||||||
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| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381282504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015165200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 512 W ROSEDALE ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172898300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2016 | ||||||||
| LastUpdateDate: | 05/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 21173 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP136986 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.