Provider Demographics
NPI:1558894956
Name:WILSON, MIKE (ORTHOPEDIC TECH)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:ORTHOPEDIC TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 N EL CAMINO REAL
Mailing Address - Street 2:STE 405
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2811
Mailing Address - Country:US
Mailing Address - Phone:760-994-2663
Mailing Address - Fax:
Practice Address - Street 1:317 N EL CAMINO REAL
Practice Address - Street 2:STE 405
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2811
Practice Address - Country:US
Practice Address - Phone:760-994-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXCPT00039417246ZX2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic Assistant