Provider Demographics
NPI:1699903757
Name:WILTBANK, CARL S (DPT)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:S
Last Name:WILTBANK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 824
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:AZ
Mailing Address - Zip Code:85936-0824
Mailing Address - Country:US
Mailing Address - Phone:928-337-3020
Mailing Address - Fax:928-337-3979
Practice Address - Street 1:80 S 13TH WEST
Practice Address - Street 2:
Practice Address - City:ST. JOHNS
Practice Address - State:AZ
Practice Address - Zip Code:85936
Practice Address - Country:US
Practice Address - Phone:928-337-3020
Practice Address - Fax:928-337-3979
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-29
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8544225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ443777Medicaid
AZZ28088Medicare PIN