Healthcare Provider Details

I. General information

NPI: 1710920178
Provider Name (Legal Business Name): TIFFANY KAY WILSON P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 W SOUTH ST
HENRIETTA TX
76365-3348
US

IV. Provider business mailing address

412 W SOUTH ST
HENRIETTA TX
76365-3348
US

V. Phone/Fax

Practice location:
  • Phone: 940-235-3403
  • Fax: 580-272-0186
Mailing address:
  • Phone: 940-235-3403
  • Fax: 580-272-0186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2381
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA04018
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: