Provider Demographics
NPI:1073935185
Name:WILSON III, LEROY (LPTA)
Entity Type:Individual
Prefix:MR
First Name:LEROY
Middle Name:
Last Name:WILSON III
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8001 WEDLOCK LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-5472
Mailing Address - Country:US
Mailing Address - Phone:702-372-0853
Mailing Address - Fax:
Practice Address - Street 1:8001 WEDLOCK LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-5472
Practice Address - Country:US
Practice Address - Phone:702-372-0853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA 0221225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant