Provider Demographics
NPI:1063186872
Name:WILSON, TEYA C
Entity type:Individual
Prefix:
First Name:TEYA
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5089 S 900 E STE 100
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5731
Mailing Address - Country:US
Mailing Address - Phone:801-743-0700
Mailing Address - Fax:801-743-0701
Practice Address - Street 1:5089 S 900 E STE 100
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84117-5731
Practice Address - Country:US
Practice Address - Phone:801-743-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5292638-4405363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care