MEDICARE: EDWINA GAUTAM WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	047589	NY

General Provider Information

NPI Number	:	1528739349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDWINA GAUTAM WILSON

Provider Business Mailing Address
First Line	:	38 FORT WASHINGTON AVE APT 34
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10032-4776
Country	:	US
Telephone Number	:	312-825-7937
Fax Number	:	914-294-0079

Provider Business Practice Location Address
First Line	:	3163 BAINBRIDGE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10467-3907
Country	:	US
Telephone Number	:	914-234-8543
Fax Number	:	914-294-0079

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2021
Last Update Date	:	09/22/2021

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Directions to “ EDWINA GAUTAM WILSON ” Practice Location

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