Provider Demographics
NPI:1629706783
Name:WILEY, MEGAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:WILEY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 RESEARCH CT STE 450
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6660
Mailing Address - Country:US
Mailing Address - Phone:770-205-5551
Mailing Address - Fax:
Practice Address - Street 1:477 PROMINENCE CT STE 100
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-6377
Practice Address - Country:US
Practice Address - Phone:401-216-9564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2023-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT016088225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPT016088OtherPHYSICAL THERAPY LICENSE NUMBER