Provider Demographics
NPI:1225034721
Name:WILSON, TONYA HENRY (ANP)
Entity type:Individual
Prefix:MRS
First Name:TONYA
Middle Name:HENRY
Last Name:WILSON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:MS
Other - First Name:TONYA
Other - Middle Name:HENRY
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3889
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-3889
Mailing Address - Country:US
Mailing Address - Phone:423-794-2450
Mailing Address - Fax:423-283-9480
Practice Address - Street 1:301 MED TECH PKWY STE 200
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2364
Practice Address - Country:US
Practice Address - Phone:423-794-1300
Practice Address - Fax:423-794-1820
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7633363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3349326Medicaid
TN4070554OtherBCBST
3703861Medicare PIN
TN4070554OtherBCBST
P00034257Medicare PIN
TN33493260Medicare PIN
P92177Medicare UPIN
3703865Medicare PIN