Basic Information
| Provider Information | |||||||||
| NPI: | 1952764425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | TABITHA | ||||||||
| MiddleName: | SUE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2324 190TH ST | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | IA | ||||||||
| PostalCode: | 508338233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7126214164 | ||||||||
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| Practice Location | |||||||||
| Address1: | 603 ROSARY DR | ||||||||
| Address2: | |||||||||
| City: | CORNING | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6413223121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2016 | ||||||||
| LastUpdateDate: | 07/24/2019 | ||||||||
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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 | 208000000X | MD-46015 | IA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.