Provider Demographics
NPI:1588393524
Name:WILSON, ASHLEY RENAE (PT, DPT)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:RENAE
Last Name:WILSON
Suffix:
Gender:F
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 1:6350 W 143RD ST STE 202
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-2890
Mailing Address - Country:US
Mailing Address - Phone:952-428-1554
Mailing Address - Fax:
Practice Address - Street 1:6350 W 143RD ST STE 202
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-2890
Practice Address - Country:US
Practice Address - Phone:952-428-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12472225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist