Individual
DR. TANYA KEZIA DANIELLE WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
1040 WISHARD BLVD, INDIANAPOLIS, IN 46202-2872
(317) 962-8893
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
01077438A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
201172370
—
IN
Enumeration date
05/02/2013
Last updated
06/14/2022
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