MEDICARE: MATTHEW J WILSON ATC

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	2255A2300X	Athletic Trainer	RT003042	PA

General Provider Information

NPI Number	:	1184353328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW J WILSON ATC

Provider Business Mailing Address
First Line	:	3295 N HILLS RD
Second Line	:
City	:	MURRYSVILLE
State	:	PA
Zip	:	15668-1319
Country	:	US
Telephone Number	:	724-422-6649
Fax Number	:

Provider Business Practice Location Address
First Line	:	612 SALT ST
Second Line	:
City	:	SALTSBURG
State	:	PA
Zip	:	15681-1128
Country	:	US
Telephone Number	:	724-639-8300
Fax Number	:	724-639-3112

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

Provider Enumeration Date	:	06/05/2022
Last Update Date	:	06/05/2022

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