MEDICARE: CARLY J WILSON MS, LAT, 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	390200000X	Student in an Organized Health Care Education/Training Program
2	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1205326642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY J WILSON MS, LAT, ATC

Provider Business Mailing Address
First Line	:	1051 SOUTHERN DR UNIT 2108
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29201-5608
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1109 W MYRTLE ST STE 200
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83702-6975
Country	:	US
Telephone Number	:	208-489-4300
Fax Number	:

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

Provider Enumeration Date	:	05/10/2018
Last Update Date	:	09/09/2021

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