Provider Demographics
NPI:1053665968
Name:WILSON, PATRICIA G (PT)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:G
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 AVE AT PORT IMPERIAL
Mailing Address - Street 2:APT 205
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-8350
Mailing Address - Country:US
Mailing Address - Phone:908-268-2378
Mailing Address - Fax:
Practice Address - Street 1:150 NORTH ST
Practice Address - Street 2:
Practice Address - City:TETERBORO
Practice Address - State:NJ
Practice Address - Zip Code:07608-1202
Practice Address - Country:US
Practice Address - Phone:201-393-9199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01374000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist