Provider Demographics
NPI:1518023696
Name:WILSON, MARCUS BRANT
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:BRANT
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 ROBERTS DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35634-2634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12200 HIGHWAY 43
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-4737
Practice Address - Country:US
Practice Address - Phone:866-537-5614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH3093225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPTH3093OtherPHYSICAL THERAPY LICENSE