Provider Demographics
NPI:1407335888
Name:ROEGGE, WILSON SD (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:WILSON
Middle Name:SD
Last Name:ROEGGE
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 1:2833 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-6011
Mailing Address - Country:US
Mailing Address - Phone:224-600-5736
Mailing Address - Fax:
Practice Address - Street 1:11509 S FORTUNA RD
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85367-7857
Practice Address - Country:US
Practice Address - Phone:928-342-8767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist