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General NPI Number Information
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NPI Number | 1750850095
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Entity Type | Individual
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Provider Name | SHAWNA SUE WILSON PTA
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Gender | Female
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Dates
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Enumeration Date | 11/15/2018
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Last Update Date | 11/15/2018
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Provider Practice Location Address
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Address Line | 502 N 9TH AVE
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City | VINTON
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State | IA
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Zip | 52349-2254
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Country | US
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Telephone | 319-472-6220
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Fax |
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Provider Business Mailing Address
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Address Line | 2409 DEBORAH DR SW
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City | CEDAR RAPIDS
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State | IA
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Zip | 52404-3714
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Country | US
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Telephone | 319-470-3751
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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 | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 092206
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License Number State | IA
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