Provider Demographics
NPI:1104028562
Name:WILSON, CAROL ANN (PT)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
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 1:5526 E 46TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-6719
Mailing Address - Country:US
Mailing Address - Phone:918-519-2223
Mailing Address - Fax:
Practice Address - Street 1:6565 S YALE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8378
Practice Address - Country:US
Practice Address - Phone:918-488-6888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT624225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist