MEDICARE: MARYANNE 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	18952	CO
2	225100000X	Physical Therapist	306577	CA

General Provider Information

NPI Number	:	1508567090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARYANNE WILSON PT

Provider Business Mailing Address
First Line	:	2706 28TH ST
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80301-1222
Country	:	US
Telephone Number	:	303-444-1290
Fax Number	:	303-444-1837

Provider Business Practice Location Address
First Line	:	2706 28TH ST
Second Line	:
City	:	BOULDER
State	:	CO
Zip	:	80301-1222
Country	:	US
Telephone Number	:	303-444-1290
Fax Number	:	303-444-1837

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

Provider Enumeration Date	:	03/13/2023
Last Update Date	:	01/19/2026

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Directions to “ MARYANNE WILSON PT” Practice Location

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