MEDICARE: WILLIAM TIMOTHY WILSON NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WE0003X	Emergency Registered Nurse	214850	TN
2	363LF0000X	Family Nurse Practitioner	28240	TN

General Provider Information

NPI Number	:	1174140008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM TIMOTHY WILSON NP

Provider Business Mailing Address
First Line	:	3300 WILLIAMS ENTERPRISE DR STE 1
Second Line	:
City	:	COOKEVILLE
State	:	TN
Zip	:	38506-4224
Country	:	US
Telephone Number	:	931-528-9222
Fax Number	:	931-854-0907

Provider Business Practice Location Address
First Line	:	3300 WILLIAMS ENTERPRISE DR STE 1
Second Line	:
City	:	COOKEVILLE
State	:	TN
Zip	:	38506-4280
Country	:	US
Telephone Number	:	931-528-9222
Fax Number	:	931-854-0907

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2020
Last Update Date	:	12/05/2022

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