Healthcare Provider Details

I. General information

NPI: 1124277553
Provider Name (Legal Business Name): TIMOTHY ALAN WIXSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2008
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1206 GLENWOOD DR
AUGUSTA GA
30904-3341
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-3494
  • Fax: 706-721-3503
Mailing address:
  • Phone: 706-364-1206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number008955
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number008955
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: