Healthcare Provider Details

I. General information

NPI: 1679645683
Provider Name (Legal Business Name): KAREN RENE WILSON PA-C, PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9100 CENTENNIAL CIR
ANCHORAGE AK
99504-1480
US

IV. Provider business mailing address

4011 FIELDSTONE XING
MISSOULA MT
59802-8602
US

V. Phone/Fax

Practice location:
  • Phone: 406-531-5276
  • Fax:
Mailing address:
  • Phone: 406-531-5276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number298
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number492
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2777
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: