Healthcare Provider Details

I. General information

NPI: 1821122383
Provider Name (Legal Business Name): CORI ANN WILSON P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 HOSPITAL DR
OSAGE BEACH MO
65065-3050
US

IV. Provider business mailing address

6005 BAYDY PEAK RD UNIT 1006
OSAGE BEACH MO
65065-3908
US

V. Phone/Fax

Practice location:
  • Phone: 573-302-2230
  • Fax: 573-302-2231
Mailing address:
  • Phone: 573-280-9369
  • Fax: 573-302-2231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2004005504
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: