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NPI Code Detail

MEDICARE: OTAVIA WILSON PTA

MEDICARE: OTAVIA WILSON PTA
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
1225200000XPhysical Therapy Assistant2173256TX

General Provider Information

NPI Number : 1538878277
Entity Type Code : Individual
Provider Name (Legal Business Name) : OTAVIA WILSON PTA
Provider Business Mailing Address
First Line : 19806 CAMPFIELD DR
Second Line :
City : KATY
State : TX
Zip : 77449-6693
Country : US
Telephone Number : 281-758-9302
Fax Number :
Provider Business Practice Location Address
First Line : 1321 PARK BAYOU DR
Second Line :
City : HOUSTON
State : TX
Zip : 77077-1507
Country : US
Telephone Number : 833-539-1367
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/21/2022
Last Update Date : 11/21/2022

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Directions to “ OTAVIA WILSON PTA” Practice Location

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