Provider Demographics
NPI:1326032947
Name:WILEY, TAMMIE FRAZIER (MD)
Entity type:Individual
Prefix:
First Name:TAMMIE
Middle Name:FRAZIER
Last Name:WILEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TAMMIE
Other - Middle Name:JEANNE
Other - Last Name:FRAZIER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2808 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4138
Mailing Address - Country:US
Mailing Address - Phone:336-765-9000
Mailing Address - Fax:336-765-5702
Practice Address - Street 1:2808 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4138
Practice Address - Country:US
Practice Address - Phone:336-765-9000
Practice Address - Fax:336-765-5702
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800537208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891163VMedicaid
NC891163VMedicaid
G70986Medicare UPIN