Provider Demographics
NPI:1558330886
Name:WILSON, FREDERICK CHARLES (PT ATC)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:CHARLES
Last Name:WILSON
Suffix:
Gender:M
Credentials:PT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18905 E 33RD STREET CT S
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64057-3336
Mailing Address - Country:US
Mailing Address - Phone:816-795-6118
Mailing Address - Fax:
Practice Address - Street 1:18905 E 33RD STREET CT S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057-3336
Practice Address - Country:US
Practice Address - Phone:816-589-0100
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107962225100000X
MO001562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer