Provider Demographics
NPI:1205210689
Name:DUKE, VIRGINIA WILSON (PT)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:WILSON
Last Name:DUKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1901A MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3711
Mailing Address - Country:US
Mailing Address - Phone:601-634-4076
Mailing Address - Fax:601-883-2232
Practice Address - Street 1:1901A MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3711
Practice Address - Country:US
Practice Address - Phone:601-634-4076
Practice Address - Fax:601-883-2232
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT5771225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist