Healthcare Provider Details

I. General information

NPI: 1366485443
Provider Name (Legal Business Name): THOMAS A. WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

778 HOFFMAN RD
WEST END NC
27376-9029
US

IV. Provider business mailing address

339 WILDLIFE RD
SANFORD NC
27332-0846
US

V. Phone/Fax

Practice location:
  • Phone: 877-472-2302
  • Fax: 877-472-2302
Mailing address:
  • Phone: 336-267-1186
  • Fax: 877-472-2302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number19427
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: