Provider Demographics
NPI:1194083709
Name:WILSON, JUDD WEST
Entity type:Individual
Prefix:
First Name:JUDD
Middle Name:WEST
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2313 OLD HENSON COVE RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28716-6872
Mailing Address - Country:US
Mailing Address - Phone:828-593-9660
Mailing Address - Fax:
Practice Address - Street 1:1702 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3419
Practice Address - Country:US
Practice Address - Phone:910-323-3184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP12366225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist