Provider Demographics
NPI:1003004193
Name:WILSON, ELIZABETH AMY (ATC)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:AMY
Last Name:WILSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 LOMA LINDA DR
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-2791
Mailing Address - Country:US
Mailing Address - Phone:717-343-9501
Mailing Address - Fax:
Practice Address - Street 1:1240 UNIVERSITY OF OREGON
Practice Address - Street 2:122 ESSLINGER
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97403-1205
Practice Address - Country:US
Practice Address - Phone:541-346-4107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer