Provider Demographics
NPI:1144558644
Name:WILBANKS, NATALIE RUTH (PA-C)
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:RUTH
Last Name:WILBANKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S MAIN ST
Mailing Address - Street 2:P.O. BOX 540
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-2154
Mailing Address - Country:US
Mailing Address - Phone:423-784-8492
Mailing Address - Fax:423-784-8358
Practice Address - Street 1:550 SUNSET TRL
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-2343
Practice Address - Country:US
Practice Address - Phone:423-784-5771
Practice Address - Fax:423-784-6185
Is Sole Proprietor?:No
Enumeration Date:2009-11-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1558363A00000X
363A00000X
TN1798363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1798OtherSTATE LICENSE
KY1558OtherSTATE LICENSE
KY7100119880Medicaid
TN1518501Medicaid
TN1518501Medicaid