Provider Demographics
NPI:1437908308
Name:WILSON, ROBERT EUGENE (PMHNP)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:EUGENE
Last Name:WILSON
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 GRAY COMMONS CIR STE 110
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-5406
Mailing Address - Country:US
Mailing Address - Phone:833-371-0509
Mailing Address - Fax:
Practice Address - Street 1:203 GRAY COMMONS CIR STE 110
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-5406
Practice Address - Country:US
Practice Address - Phone:833-371-0509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024186778363LP0808X
TN33192363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health