MEDICARE: MR. JASON L WILHELM PTA

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	225200000X	Physical Therapy Assistant	7977A	AZ

General Provider Information

NPI Number	:	1831359066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JASON L WILHELM PTA

Provider Business Mailing Address
First Line	:	726 W AIRE LIBRE AVE
Second Line	:	C/O KIDS INSTRUCTION FOR DEVELOPMENTAL SERVICES
City	:	PHOENIX
State	:	AZ
Zip	:	85023-7910
Country	:	US
Telephone Number	:	602-938-9839
Fax Number	:	602-938-9839

Provider Business Practice Location Address
First Line	:	726 W AIRE LIBRE AVE
Second Line	:	C/O KIDS INSTRUCTION FOR DEVELOPMENTAL SERVICES
City	:	PHOENIX
State	:	AZ
Zip	:	85023-7910
Country	:	US
Telephone Number	:	602-938-9839
Fax Number	:	602-938-9839

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

Provider Enumeration Date	:	06/11/2008
Last Update Date	:	06/11/2008

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