Basic Information
| Provider Information | |||||||||
| NPI: | 1851367163 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | ROBIN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11784 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379391784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655882928 | ||||||||
| FaxNumber: | 8654509374 | ||||||||
| Practice Location | |||||||||
| Address1: | 137 BLOUNT AVE | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 37871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656325992 | ||||||||
| FaxNumber: | 8656325316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 11/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 15034 | TN | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 1740454 | 01 | TN | UHC | OTHER | 4011753 | 01 | TN | BCBS OF TN | OTHER | 3041941 | 05 | TN | MEDICAID | 64913189 | 05 | KY | MEDICAID |