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General NPI Number Information
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NPI Number | 1821872987
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Entity Type | Individual
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Provider Name | TANNER BRYCE WILSON PT, DPT
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Gender | Male
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Dates
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Enumeration Date | 08/21/2023
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Last Update Date | 08/21/2023
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Provider Practice Location Address
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Address Line | 703 E MAIN ST UNIT 1
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City | LEBANON
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State | KY
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Zip | 40033-8696
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Country | US
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Telephone | 270-699-9503
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Fax |
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Provider Business Mailing Address
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Address Line | 145 HEART LN
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City | CAMPBELLSVILLE
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State | KY
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Zip | 42718-7376
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Country | US
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Telephone | 270-670-2823
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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 | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 008824
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License Number State | KY
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