Provider Demographics
NPI:1053864306
Name:WILSON, MICHAEL TYLER (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TYLER
Last Name:WILSON
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 CENTRAL METHODIST SQ
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MO
Mailing Address - Zip Code:65248-1104
Mailing Address - Country:US
Mailing Address - Phone:636-577-5062
Mailing Address - Fax:
Practice Address - Street 1:411 CENTRAL METHODIST SQ
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:MO
Practice Address - Zip Code:65248-1104
Practice Address - Country:US
Practice Address - Phone:636-577-5062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20160234842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer