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General NPI Number Information
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NPI Number | 1093558322
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Entity Type | Individual
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Provider Name | IAN WILSON
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Gender | Male
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Dates
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Enumeration Date | 06/14/2024
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Last Update Date | 06/14/2024
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Provider Practice Location Address
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Address Line | 4031 PACIFIC HWY
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City | SAN DIEGO
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State | CA
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Zip | 92110-2028
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Country | US
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Telephone | 408-628-8020
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Fax |
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Provider Business Mailing Address
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Address Line | 10500 SEA PEARL CV UNIT 1
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City | SAN DIEGO
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State | CA
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Zip | 92130-8742
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 306064
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License Number State | CA
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