Healthcare Provider Details

I. General information

NPI: 1811471444
Provider Name (Legal Business Name): CASEY WILSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040A JACKSON AVE UNIT A202
JOINT BASE LEWIS MCCHORD WA
98431-1235
US

IV. Provider business mailing address

S DIVISION ST
FORT LEWIS WA
98433
US

V. Phone/Fax

Practice location:
  • Phone: 253-988-4550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA161326275
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: