Provider Demographics
NPI:1659331239
Name:WILSON, CLAYTON MATTHEW (AT, C, OTC)
Entity Type:Individual
Prefix:MR
First Name:CLAYTON
Middle Name:MATTHEW
Last Name:WILSON
Suffix:
Gender:M
Credentials:AT, C, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 CENTENNIAL HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3265
Mailing Address - Country:US
Mailing Address - Phone:307-265-7205
Mailing Address - Fax:307-235-6262
Practice Address - Street 1:4140 CENTENNIAL HILLS BLVD
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-3265
Practice Address - Country:US
Practice Address - Phone:307-265-7205
Practice Address - Fax:307-235-6262
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZX2200X
WY0872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY087OtherCERTIFIED ATHLETIC TRAINER
WY16-0200OtherCERTIFIED ORTHOPEDIC TECHNOLOGIST