Provider Demographics
NPI:1235695933
Name:WILSON, TRAVIS ALEXANDER (PT, DPT)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:ALEXANDER
Last Name:WILSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 CONCORD PLAZA DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-6991
Mailing Address - Country:US
Mailing Address - Phone:210-804-5416
Mailing Address - Fax:210-678-4142
Practice Address - Street 1:10415 STATE HIGHWAY 151 STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-4553
Practice Address - Country:US
Practice Address - Phone:210-647-9970
Practice Address - Fax:210-647-7229
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1309709225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1309709OtherTEXAS PHYSICAL THERAPIST LICENSE