Healthcare Provider Details

I. General information

NPI: 1841166485
Provider Name (Legal Business Name): JUSTIN CHUAN WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 10/13/2025
Certification Date: 10/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20522 FALCONS LANDING CIR
STERLING VA
20165-7595
US

IV. Provider business mailing address

6362 BONHAM PL
CENTREVILLE VA
20121-2650
US

V. Phone/Fax

Practice location:
  • Phone: 703-404-5100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306606602
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: