Provider Demographics
NPI:1194295592
Name:WILSON, JOSHUA M (DC)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 SW ALACHUA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5213
Mailing Address - Country:US
Mailing Address - Phone:386-719-5656
Mailing Address - Fax:386-719-5654
Practice Address - Street 1:444 SW ALACHUA AVENUE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5213
Practice Address - Country:US
Practice Address - Phone:386-719-5656
Practice Address - Fax:386-719-5654
Is Sole Proprietor?:No
Enumeration Date:2018-11-28
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR010131111N00000X
FLCH12879111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor