Provider Demographics
NPI:1619113123
Name:WILBUR, AISHA CORREA (DPT)
Entity Type:Individual
Prefix:
First Name:AISHA
Middle Name:CORREA
Last Name:WILBUR
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 PHILLIPS FIELD RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3933
Mailing Address - Country:US
Mailing Address - Phone:907-456-5990
Mailing Address - Fax:907-374-8023
Practice Address - Street 1:2555 PHILLIPS FIELD RD
Practice Address - Street 2:SUITE 202
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3933
Practice Address - Country:US
Practice Address - Phone:907-456-5990
Practice Address - Fax:907-374-8023
Is Sole Proprietor?:No
Enumeration Date:2009-01-05
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK21082251X0800X, 225100000X
AZ82252251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1029463Medicaid
AKK162572Medicare UPIN