Provider Demographics
NPI:1639728116
Name:WILSON, JOHN ANDREW
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANDREW
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4022 TENNYSON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80212-2104
Mailing Address - Country:US
Mailing Address - Phone:303-435-8326
Mailing Address - Fax:
Practice Address - Street 1:4022 TENNYSON ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80212-2104
Practice Address - Country:US
Practice Address - Phone:303-435-8326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-08
Last Update Date:2019-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COMT.0017543225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist