Healthcare Provider Details

I. General information

NPI: 1619173549
Provider Name (Legal Business Name): TIMOTHY ALLEN WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8930 EVANSTON AVE
KANSAS CITY MO
64138-4732
US

IV. Provider business mailing address

8930 EVANSTON AVE
KANSAS CITY MO
64138-4732
US

V. Phone/Fax

Practice location:
  • Phone: 816-617-1398
  • Fax: 816-832-8236
Mailing address:
  • Phone: 816-617-1398
  • Fax: 816-832-8236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR3A87
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberR3A87
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: