MEDICARE: MR. STUART ANTHONY WILSON MS, 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	7018	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	WI672666	OTHER	CO	BCBS

General Provider Information

NPI Number	:	1710935085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STUART ANTHONY WILSON MS, PT

Provider Business Mailing Address
First Line	:	1169 S ALKIRE ST
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80228-3113
Country	:	US
Telephone Number	:	720-295-6098
Fax Number	:

Provider Business Practice Location Address
First Line	:	1169 S ALKIRE ST
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80228-3113
Country	:	US
Telephone Number	:	720-295-6098
Fax Number	:

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

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	10/22/2020

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