Provider Demographics
NPI:1124240098
Name:WILSON, KRISTIN L (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 ENON SPRINGS ROAD EAST
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167
Mailing Address - Country:US
Mailing Address - Phone:615-459-0005
Mailing Address - Fax:615-459-5222
Practice Address - Street 1:115 ENON SPRINGS ROAD EAST
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167
Practice Address - Country:US
Practice Address - Phone:615-459-0005
Practice Address - Fax:615-459-5222
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN1109363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant