Provider Demographics
NPI:1366622581
Name:WILSON, DAVID (PT,CWS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:PT,CWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 FALCON DR
Mailing Address - Street 2:
Mailing Address - City:WOODLAWN
Mailing Address - State:VA
Mailing Address - Zip Code:24381-3303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2846
Practice Address - Country:US
Practice Address - Phone:276-236-8974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005631225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist