Provider Demographics
NPI:1679818843
Name:WILSON, STEVEN GERARD (PT)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:GERARD
Last Name:WILSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 DINWIDDIE AVE
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23229-5830
Mailing Address - Country:US
Mailing Address - Phone:804-288-6412
Mailing Address - Fax:804-717-8368
Practice Address - Street 1:6701 IRONBRIDGE PKWY
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-1469
Practice Address - Country:US
Practice Address - Phone:804-717-8367
Practice Address - Fax:804-717-8368
Is Sole Proprietor?:No
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202327225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist