Provider Demographics
NPI:1922081306
Name:WILSON, PATRICK CHARLES (MPT)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:CHARLES
Last Name:WILSON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:16120 W DODGE RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-2049
Practice Address - Country:US
Practice Address - Phone:402-354-0410
Practice Address - Fax:402-354-0415
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1268225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025941700Medicaid
NE10025895900Medicaid
NE10025896000Medicaid
NE10026056700Medicaid
IA1992081306Medicaid
NE10025896100Medicaid
NE10026252200Medicaid
NE10025896000Medicaid