MEDICARE: THOMAS GROVE WILSON CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	CNP 4710	MN
2	363LG0600X	Gerontology Nurse Practitioner	CNP 4710	MN
3	363LP2300X	Primary Care Nurse Practitioner	CNP 4710	MN

General Provider Information

NPI Number	:	1316495401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS GROVE WILSON CNP

Provider Business Mailing Address
First Line	:	3100 KENNARD ST
Second Line	:	SUITE 100
City	:	MAPLEWOOD
State	:	MN
Zip	:	55109-5465
Country	:	US
Telephone Number	:	651-232-7800
Fax Number	:	651-232-7940

Provider Business Practice Location Address
First Line	:	3100 KENNARD ST
Second Line	:	SUITE 100
City	:	MAPLEWOOD
State	:	MN
Zip	:	55109-5465
Country	:	US
Telephone Number	:	651-232-7800
Fax Number	:	651-232-7940

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2016
Last Update Date	:	09/16/2016

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