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General NPI Number Information
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NPI Number | 1407733876
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Entity Type | Individual
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Provider Name | WILSON RODRIGUEZ JR.
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Gender | Male
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Dates
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Enumeration Date | 08/18/2025
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Last Update Date | 08/18/2025
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Provider Practice Location Address
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Address Line | 1000 MAR WALT DR
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6708
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Country | US
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Telephone | 850-863-7581
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Fax |
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Provider Business Mailing Address
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Address Line | 2882 AZALEA DR
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City | EGLIN AFB
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State | FL
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Zip | 32542-3216
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Country | US
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Telephone | 908-644-5926
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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 | 33782
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License Number State | FL
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