Provider Demographics
NPI:1285021071
Name:WILSON, JUSTIN ALAN (OPA-C)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:ALAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:OPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7208 HARDY DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-2207
Mailing Address - Country:US
Mailing Address - Phone:512-656-6143
Mailing Address - Fax:
Practice Address - Street 1:16020 PARK VALLEY DR
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-3573
Practice Address - Country:US
Practice Address - Phone:512-477-6341
Practice Address - Fax:512-477-1959
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
913246ZC0007X, 246ZS0410X, 246ZX2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic AssistantGroup - Single Specialty
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical TechnologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
#913OtherORTHOPEDIC PHYSICIAN ASSISTANTS