Provider Demographics
NPI:1710288790
Name:WILSON, PATRICK RICHARD (PT)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:RICHARD
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 1:1100 N J ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-2438
Mailing Address - Country:US
Mailing Address - Phone:360-533-3853
Mailing Address - Fax:
Practice Address - Street 1:220 W 1ST ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-6216
Practice Address - Country:US
Practice Address - Phone:360-533-3853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60184017225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist