MEDICARE: PAUL 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	62298	OR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	R195362	OTHER	OR	MEDICARE
3	R194490	OTHER	OR	MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578091344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAUL WILSON PT

Provider Business Mailing Address
First Line	:	16083 SW UPPER BOONES FERRY RD STE 300
Second Line	:
City	:	TIGARD
State	:	OR
Zip	:	97224-7736
Country	:	US
Telephone Number	:	800-219-8835
Fax Number	:	503-639-9699

Provider Business Practice Location Address
First Line	:	2005 ELM ST STE 200
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-2781
Country	:	US
Telephone Number	:	503-357-9810
Fax Number	:	503-357-9819

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

Provider Enumeration Date	:	05/24/2017
Last Update Date	:	07/27/2017

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Directions to “ PAUL WILSON PT” Practice Location

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