Provider Demographics
NPI:1043896889
Name:WILSIE, COLE JORDAN (PTA)
Entity Type:Individual
Prefix:
First Name:COLE
Middle Name:JORDAN
Last Name:WILSIE
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 1:2437 N PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-1610
Mailing Address - Country:US
Mailing Address - Phone:714-604-8576
Mailing Address - Fax:
Practice Address - Street 1:18785 BROOKHURST ST STE 104
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7300
Practice Address - Country:US
Practice Address - Phone:657-301-4967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51134225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant