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General NPI Number Information
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NPI Number | 1194113704
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Entity Type | Individual
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Provider Name | NICHOLAS EVERETT WILKINSON PTA
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Gender | Male
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Dates
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Enumeration Date | 01/05/2015
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Last Update Date | 01/05/2015
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Provider Practice Location Address
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Address Line | 901 CALLE AMANECER
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City | SAN CLEMENTE
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State | CA
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Zip | 92673-6278
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Country | US
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Telephone | 949-366-6785
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 73993
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City | SAN CLEMENTE
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State | CA
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Zip | 92673-0134
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Country | US
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Telephone | 949-366-6785
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | AT 10466
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License Number State | CA
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