MEDICARE: GLENDA F 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	PT 2610	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y2361	OTHER	FL	BC/BS

General Provider Information

NPI Number	:	1871516682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENDA F WILSON PT

Provider Business Mailing Address
First Line	:	2101 NORTHSIDE DR
Second Line	:	SUITE 502
City	:	PANAMA CITY
State	:	FL
Zip	:	32405
Country	:	US
Telephone Number	:	850-913-7040
Fax Number	:	850-913-0290

Provider Business Practice Location Address
First Line	:	2101 NORTHSIDE DR UNIT 502
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-3687
Country	:	US
Telephone Number	:	850-913-7040
Fax Number	:	850-913-0290

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

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2007

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