Healthcare Provider Details

I. General information

NPI: 1346554185
Provider Name (Legal Business Name): MARK L WILSON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 01/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1262 W CLAIREMONT AVE
EAU CLAIRE WI
54701-6125
US

IV. Provider business mailing address

1460 CURVE CREST BLVD W
STILLWATER MN
55082-6070
US

V. Phone/Fax

Practice location:
  • Phone: 715-858-4610
  • Fax:
Mailing address:
  • Phone: 651-439-8283
  • Fax: 651-439-0576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8136
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: