Provider Demographics
NPI:1316181217
Name:WILSON, JEFFREY DAVID (PT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DAVID
Last Name:WILSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CANALVIEW MALL
Mailing Address - Street 2:SUITE C
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-1769
Mailing Address - Country:US
Mailing Address - Phone:315-593-8786
Mailing Address - Fax:315-598-5538
Practice Address - Street 1:10 CANALVIEW MALL
Practice Address - Street 2:SUITE C
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-1769
Practice Address - Country:US
Practice Address - Phone:315-593-8786
Practice Address - Fax:315-598-5538
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0086361225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11956359OtherCAQH