Healthcare Provider Details

I. General information

NPI: 1487831020
Provider Name (Legal Business Name): CASSANDRA L WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2008
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 CINEMA DR
ELLIJAY GA
30540-2592
US

IV. Provider business mailing address

165 BLUE RIDGE OVERLOOK
BLUE RIDGE GA
30513-4431
US

V. Phone/Fax

Practice location:
  • Phone: 706-635-6898
  • Fax: 706-635-6885
Mailing address:
  • Phone: 706-946-5607
  • Fax: 706-374-7628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number62301
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: