Healthcare Provider Details

I. General information

NPI: 1366374712
Provider Name (Legal Business Name): DYLAN LEE WILSON PT,DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 KY-92 SUITE 4
WILLIAMSBURG KY
40769
US

IV. Provider business mailing address

510 WARD CEMETERY RD
CORBIN KY
40701-9585
US

V. Phone/Fax

Practice location:
  • Phone: 606-539-7257
  • Fax: 606-539-7256
Mailing address:
  • Phone: 606-515-8944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number009548
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: