Healthcare Provider Details

I. General information

NPI: 1497045728
Provider Name (Legal Business Name): WILLIAM CARROLL WILSON PA-C, MMSC.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 05/17/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 N LYERLY ST STE 200
CHATTANOOGA TN
37404-2728
US

IV. Provider business mailing address

281 N LYERLY ST STE 200
CHATTANOOGA TN
37404-2728
US

V. Phone/Fax

Practice location:
  • Phone: 423-698-0850
  • Fax: 423-698-0511
Mailing address:
  • Phone: 423-698-0850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA0000001053
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: