Provider Demographics
NPI:1518303361
Name:WILSON, KRISTOFER MICHAEL (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTOFER
Middle Name:MICHAEL
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 1:325 N MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-8005
Mailing Address - Country:US
Mailing Address - Phone:937-806-0318
Mailing Address - Fax:937-806-0319
Practice Address - Street 1:325 N MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-8005
Practice Address - Country:US
Practice Address - Phone:937-806-0318
Practice Address - Fax:937-806-0319
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT014219225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist