Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PP0204X | Pediatric Emergency Physician | 2020012908 | MO |
N | 208000000X | Pediatrician | 2020012908 | MO |
NPI | 1457871006 |
---|---|
Provider Name | Dr. Timothy Andrew Wilson |
First Address | Saint Louis, MO 63110-1002 |
Second Address | Saint Louis, MO 63110-1002 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2017 |
Last Update Date | 02/07/2020 |