Healthcare Provider Details

I. General information

NPI: 1457873440
Provider Name (Legal Business Name): MISS TAMARA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 07/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 PEGER RD STE 106
FAIRBANKS AK
99709-5305
US

IV. Provider business mailing address

2080 FRUSTRATION TRL
FAIRBANKS AK
99709-2733
US

V. Phone/Fax

Practice location:
  • Phone: 907-378-5306
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: