Provider Demographics
NPI:1003877507
Name:WILSON, GREGORY D (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:D
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 W MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:PA
Mailing Address - Zip Code:15666-1846
Mailing Address - Country:US
Mailing Address - Phone:724-542-8864
Mailing Address - Fax:724-542-8086
Practice Address - Street 1:633 W MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:PA
Practice Address - Zip Code:15666-1846
Practice Address - Country:US
Practice Address - Phone:724-542-8864
Practice Address - Fax:724-542-8086
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-01
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC008014L111NS0005X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU91326Medicare UPIN
PA059888Medicare ID - Type Unspecified