Healthcare Provider Details

I. General information

NPI: 1932533171
Provider Name (Legal Business Name): JEFFERY MORGAN WILSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2013
Last Update Date: 08/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2217 DILLON RD
CLOVIS NM
88101-9454
US

IV. Provider business mailing address

2272 TAOS CT
PORTALES NM
88130-9386
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-7356
  • Fax:
Mailing address:
  • Phone: 239-791-9308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number4368
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: