Provider Demographics
NPI:1689794927
Name:WILMES, NATHAN JOSEPH (MED ATC, LAT, CSCS)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:JOSEPH
Last Name:WILMES
Suffix:
Gender:M
Credentials:MED ATC, LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 LONE EAGLE TRL
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-6204
Mailing Address - Country:US
Mailing Address - Phone:636-928-4342
Mailing Address - Fax:
Practice Address - Street 1:4800 MEXICO RD
Practice Address - Street 2:SUITE 104
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1666
Practice Address - Country:US
Practice Address - Phone:636-928-4199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1150912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer