Provider Demographics
NPI:1679645683
Name:WILSON, KAREN RENE (PA-C, PT)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:RENE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4011 FIELDSTONE XING
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-8602
Mailing Address - Country:US
Mailing Address - Phone:406-531-5276
Mailing Address - Fax:
Practice Address - Street 1:9100 CENTENNIAL CIR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-1480
Practice Address - Country:US
Practice Address - Phone:406-531-5276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT492225100000X
MT298363AM0700X
AK2777225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1679645683Medicaid
MT4302623Medicaid
000083827Medicare ID - Type Unspecified
AK1679645683Medicaid