Provider Demographics
NPI:1518087154
Name:WILSON, DOUGLAS K (DPT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:K
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 S GREELEY HWY STE A
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-3063
Mailing Address - Country:US
Mailing Address - Phone:307-772-0955
Mailing Address - Fax:307-772-0953
Practice Address - Street 1:1217 S GREELEY HWY STE A
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-3063
Practice Address - Country:US
Practice Address - Phone:307-772-0955
Practice Address - Fax:307-772-0953
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY775225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY114493600Medicaid
WY114493600Medicaid