Provider Demographics
NPI:1790759819
Name:WILSON, MICHAEL A (MSPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:587 COACH HILL CT
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-1735
Mailing Address - Country:US
Mailing Address - Phone:484-574-1434
Mailing Address - Fax:
Practice Address - Street 1:525 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-4539
Practice Address - Country:US
Practice Address - Phone:610-449-8400
Practice Address - Fax:610-449-6392
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT016637225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1605505OtherBLUE SHIELD
PA2283570000OtherIBC
PAQ07438Medicare UPIN
PA2283570000OtherIBC