Provider Demographics
NPI:1326878711
Name:WILSON, NICHOLAS RYAN (LMT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RYAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4250 SW 182ND AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97078-1650
Mailing Address - Country:US
Mailing Address - Phone:503-764-7595
Mailing Address - Fax:
Practice Address - Street 1:4250 SW 182ND AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97078-1650
Practice Address - Country:US
Practice Address - Phone:503-764-7595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27466225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist