Provider Demographics
NPI:1114743101
Name:WILSON, DEREK TYLER (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:TYLER
Last Name:WILSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11528 S 53RD AVE
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-4523
Mailing Address - Country:US
Mailing Address - Phone:480-559-4863
Mailing Address - Fax:
Practice Address - Street 1:8410 W THOMAS RD STE 136
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3374
Practice Address - Country:US
Practice Address - Phone:623-247-4478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-033905225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist