MEDICARE: SEQUYOAH JAMIE WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1744P3200X	Prosthetics Case Management

General Provider Information

NPI Number	:	1124981212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SEQUYOAH JAMIE WILSON

Provider Business Mailing Address
First Line	:	13026 N CAVE CREEK RD STE 204
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85022-5199
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13026 N CAVE CREEK RD STE 204
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85022-5199
Country	:	US
Telephone Number	:	623-806-0929
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2025
Last Update Date	:	12/05/2025

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