Provider Demographics
NPI:1588979199
Name:WILSON, CHRISTOPHER RESHAUD (PTA)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:RESHAUD
Last Name:WILSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 HAYTER DR
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37813-2625
Mailing Address - Country:US
Mailing Address - Phone:423-258-1416
Mailing Address - Fax:
Practice Address - Street 1:5001 STATESMAN DR
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-2414
Practice Address - Country:US
Practice Address - Phone:877-853-1601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4777225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant