Provider Demographics
NPI:1881034528
Name:WILSON, ASANI (PT)
Entity Type:Individual
Prefix:
First Name:ASANI
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 NW HAWTHORNE AV
Mailing Address - Street 2:# 103
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526
Mailing Address - Country:US
Mailing Address - Phone:541-476-2502
Mailing Address - Fax:541-476-2397
Practice Address - Street 1:1701 NW HAWTHORNE AV
Practice Address - Street 2:#103
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526
Practice Address - Country:US
Practice Address - Phone:541-592-6580
Practice Address - Fax:541-592-5489
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist