Provider Demographics
NPI:1538172697
Name:WILBERT, DAVID JEFFREY (PA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JEFFREY
Last Name:WILBERT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 S MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:38230-2104
Mailing Address - Country:US
Mailing Address - Phone:731-235-0555
Mailing Address - Fax:731-235-0559
Practice Address - Street 1:801 S MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:TN
Practice Address - Zip Code:38230-2104
Practice Address - Country:US
Practice Address - Phone:731-235-0555
Practice Address - Fax:731-235-0559
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1396363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1396OtherSTATE LICENSE
TNS53909Medicare UPIN