Healthcare Provider Details

I. General information

NPI: 1629450457
Provider Name (Legal Business Name): MICHAEL TODD WILKERSON FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 07/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3114 BROWNS MILL RD
JOHNSON CITY TN
37604-1417
US

IV. Provider business mailing address

3114 BROWNS MILL RD
JOHNSON CITY TN
37604-1417
US

V. Phone/Fax

Practice location:
  • Phone: 423-631-0432
  • Fax: 423-232-8818
Mailing address:
  • Phone: 423-963-0754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN0000019438
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: