Provider Demographics
NPI:1740382027
Name:WILSON, GREGORY EDWARD (PT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:EDWARD
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 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:1615 US HIGHWAY 17
Practice Address - Street 2:SUITE 9
Practice Address - City:YOUNG HARRIS
Practice Address - State:GA
Practice Address - Zip Code:30582
Practice Address - Country:US
Practice Address - Phone:706-896-2771
Practice Address - Fax:706-896-2772
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006281225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116807Medicare ID - Type UnspecifiedGROUP NUMBER