Provider Demographics
NPI:1821238932
Name:WILSON, BRIAN S (DPT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:S
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 NW ELKS DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2350 NW CENTURY DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330
Practice Address - Country:US
Practice Address - Phone:541-754-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-02
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5887225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500606353Medicaid
ORR146081Medicare PIN