Provider Demographics
NPI:1467726455
Name:WILSON, SHELBY I (PT)
Entity Type:Individual
Prefix:MRS
First Name:SHELBY
Middle Name:I
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16451 SAINT JAMES CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99516
Mailing Address - Country:US
Mailing Address - Phone:907-336-9353
Mailing Address - Fax:
Practice Address - Street 1:110 W 38TH AVE STE 4A
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-5677
Practice Address - Country:US
Practice Address - Phone:907-561-1478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1624174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist