Provider Demographics
NPI:1821122383
Name:WILSON, CORI ANN (PTA)
Entity Type:Individual
Prefix:
First Name:CORI
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6005 BAYDY PEAK RD UNIT 1006
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3908
Mailing Address - Country:US
Mailing Address - Phone:573-280-9369
Mailing Address - Fax:573-302-2231
Practice Address - Street 1:54 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3050
Practice Address - Country:US
Practice Address - Phone:573-302-2230
Practice Address - Fax:573-302-2231
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004005504225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant