MEDICARE: JAMES K WILSON A.T.C., L.A.T.

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	2255A2300X	Athletic Trainer	1188	TX

General Provider Information

NPI Number	:	1922036425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES K WILSON A.T.C., L.A.T.

Provider Business Mailing Address
First Line	:	3807 APPALACHIAN TRL
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77345-4931
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6620 MAIN ST
Second Line	:	13TH FLOOR
City	:	HOUSTON
State	:	TX
Zip	:	77030-2305
Country	:	US
Telephone Number	:	713-986-5595
Fax Number	:	713-986-5591

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

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	07/08/2007

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