Provider Demographics
NPI:1699817791
Name:WILSON, DUSTIN RAY (MS ATC CSCS)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:RAY
Last Name:WILSON
Suffix:
Gender:M
Credentials:MS ATC CSCS
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Mailing Address - Street 1:130 OLD SCOTTSVILLE LOOP 1 RD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-8750
Mailing Address - Country:US
Mailing Address - Phone:270-745-6029
Mailing Address - Fax:270-745-5333
Practice Address - Street 1:WESTERN KENTUCKY UNIVESITY ATHLETIC TRAINING
Practice Address - Street 2:1605 AVENUE OF CHAMPIONS
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-6412
Practice Address - Country:US
Practice Address - Phone:270-745-6029
Practice Address - Fax:270-745-5333
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KYAT5252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer