Provider Demographics
NPI:1588163935
Name:WILSON, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2507 E BROW RD
Mailing Address - Street 2:
Mailing Address - City:SIGNAL MOUNTAIN
Mailing Address - State:TN
Mailing Address - Zip Code:37377-3500
Mailing Address - Country:US
Mailing Address - Phone:615-556-0163
Mailing Address - Fax:
Practice Address - Street 1:615 MCCALLIE AVE DEPT 6606
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2504
Practice Address - Country:US
Practice Address - Phone:423-425-4323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty