Healthcare Provider Details

I. General information

NPI: 1760552715
Provider Name (Legal Business Name): DEBORAH WILSON PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEBBIE WILSON

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DRIVE
MORGANTOWN WV
26506
US

IV. Provider business mailing address

9051 TAMIAMI TRL N STE 104
NAPLES FL
34108-2520
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-4118
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number27628
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: