Healthcare Provider Details

I. General information

NPI: 1760149991
Provider Name (Legal Business Name): CORA WILSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2021
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 MATHERLY ST
CROSSVILLE TN
38555-1001
US

IV. Provider business mailing address

181 MATHERLY ST
CROSSVILLE TN
38555-1001
US

V. Phone/Fax

Practice location:
  • Phone: 931-644-5423
  • Fax: 931-337-0155
Mailing address:
  • Phone: 931-644-5423
  • Fax: 931-710-5728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4795
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: