MEDICARE: ANDREA L WILSON PT

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	225100000X	Physical Therapist	05008306A	IN

General Provider Information

NPI Number	:	1194753582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA L WILSON PT

Provider Business Mailing Address
First Line	:	201 PENNSYLVANIA PKWY
Second Line	:	STE 100
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46280-1393
Country	:	US
Telephone Number	:	317-817-1200
Fax Number	:	317-817-1220

Provider Business Practice Location Address
First Line	:	201 PENNSYLVANIA PKWY
Second Line	:	STE 100
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46280-1393
Country	:	US
Telephone Number	:	317-817-1200
Fax Number	:	317-817-1220

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	07/26/2016

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