Healthcare Provider Details

I. General information

NPI: 1992642532
Provider Name (Legal Business Name): DEREK WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9010 S PRIEST DR APT 3082
TEMPE AZ
85284-1098
US

IV. Provider business mailing address

9010 S PRIEST DR APT 3082
TEMPE AZ
85284-1098
US

V. Phone/Fax

Practice location:
  • Phone: 480-310-0976
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number30438
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: