Provider Demographics
NPI:1427400480
Name:WILSON, NICHOLAS ROBERT-VINCENT (ATC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ROBERT-VINCENT
Last Name:WILSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 W 12TH ST APT J
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-1792
Mailing Address - Country:US
Mailing Address - Phone:989-590-2082
Mailing Address - Fax:
Practice Address - Street 1:513 W 12TH ST APT J
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:KS
Practice Address - Zip Code:67114-1792
Practice Address - Country:US
Practice Address - Phone:989-590-2082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-01
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer