Provider Demographics
NPI:1013360270
Name:WILSON, JAMES (LAT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5303 COLORADO DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76542-5322
Mailing Address - Country:US
Mailing Address - Phone:254-336-0862
Mailing Address - Fax:
Practice Address - Street 1:1001 E FM 2410 RD
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-6845
Practice Address - Country:US
Practice Address - Phone:254-336-0862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer