Provider Demographics
NPI:1417471426
Name:WILSON, GLENN GORDON (CP(C)CO,BOCP)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:GORDON
Last Name:WILSON
Suffix:
Gender:M
Credentials:CP(C)CO,BOCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4214 S SULLIVAN RD
Mailing Address - Street 2:
Mailing Address - City:VERADALE
Mailing Address - State:WA
Mailing Address - Zip Code:99037-9187
Mailing Address - Country:US
Mailing Address - Phone:406-750-0123
Mailing Address - Fax:
Practice Address - Street 1:514 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2620
Practice Address - Country:US
Practice Address - Phone:509-624-3314
Practice Address - Fax:509-787-0952
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPS60602304224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist