Provider Demographics
NPI:1316495401
Name:WILSON, THOMAS GROVE (CNP)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:GROVE
Last Name:WILSON
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 KENNARD ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-5465
Mailing Address - Country:US
Mailing Address - Phone:651-232-7800
Mailing Address - Fax:651-232-7940
Practice Address - Street 1:3100 KENNARD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-5465
Practice Address - Country:US
Practice Address - Phone:651-232-7800
Practice Address - Fax:651-232-7940
Is Sole Proprietor?:No
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP 4710363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology