Healthcare Provider Details

I. General information

NPI: 1750825634
Provider Name (Legal Business Name): MICHAEL WILSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2016
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 S MAIN ST
FARMVILLE VA
23901
US

IV. Provider business mailing address

935 S MAIN ST
FARMVILLE VA
23901-2211
US

V. Phone/Fax

Practice location:
  • Phone: 434-315-5362
  • Fax: 434-808-1048
Mailing address:
  • Phone: 434-315-2920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305208903
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: