Provider Demographics
NPI:1114107737
Name:WILSON, JOSEPH DANIEL (ATC; LAT)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:DANIEL
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 1:320 N WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-2857
Mailing Address - Country:US
Mailing Address - Phone:478-445-1787
Mailing Address - Fax:478-445-1790
Practice Address - Street 1:320 N WAYNE ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2857
Practice Address - Country:US
Practice Address - Phone:478-445-1787
Practice Address - Fax:478-445-1790
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0014592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer