1700247285 NPI number — MRS. TIFFANY ELIZABETH WILSON FNP-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700247285 NPI number — MRS. TIFFANY ELIZABETH WILSON FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
TIFFANY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700247285
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8441 STATE HWY 47
Provider Second Line Business Mailing Address:
STE 3115
Provider Business Mailing Address City Name:
BRYAN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77807-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-436-9703
Provider Business Mailing Address Fax Number:
979-436-9703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1602 ROCK PRAIRIE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLEGE STATION
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77845-8306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-693-0737
Provider Business Practice Location Address Fax Number:
979-693-7442
Provider Enumeration Date:
03/11/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP130206 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2G3166 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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