Provider Demographics
NPI:1427230663
Name:WILSON, NATHAN G (LPT)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:G
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 APEX DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1282
Mailing Address - Country:US
Mailing Address - Phone:618-441-0482
Mailing Address - Fax:618-441-0482
Practice Address - Street 1:790 N. HWY 67
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-5108
Practice Address - Country:US
Practice Address - Phone:314-972-1442
Practice Address - Fax:314-972-1533
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016087208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08220357OtherBCBS GROUP#
IL207465Medicare PIN