Provider Demographics
NPI:1861491185
Name:WILSON, LAURA CHRISTINE (DPT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:CHRISTINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:CHRISTINE
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1450 E PRATER WAY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89434-8972
Mailing Address - Country:US
Mailing Address - Phone:775-331-1199
Mailing Address - Fax:775-331-1180
Practice Address - Street 1:1450 E PRATER WAY
Practice Address - Street 2:SUITE 103
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89434-8972
Practice Address - Country:US
Practice Address - Phone:775-331-1199
Practice Address - Fax:775-331-1180
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6741225100000X
NV1707225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPENDINGMedicare ID - Type Unspecified