Provider Demographics
NPI:1760404990
Name:WILSON, FREDERICK CHARLES (DC)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:CHARLES
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 AABC, STE.C
Mailing Address - Street 2:
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81611
Mailing Address - Country:US
Mailing Address - Phone:970-925-4846
Mailing Address - Fax:970-925-4848
Practice Address - Street 1:300 AABC
Practice Address - Street 2:STE C
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611
Practice Address - Country:US
Practice Address - Phone:970-925-4846
Practice Address - Fax:970-925-4848
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2237111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO44-793Medicare ID - Type Unspecified
COU84448Medicare UPIN