Provider Demographics
NPI:1942591672
Name:WILSON, GEORGE JAY (MSPT)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:JAY
Last Name:WILSON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CEDAR CT
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11937-2246
Mailing Address - Country:US
Mailing Address - Phone:631-903-7996
Mailing Address - Fax:
Practice Address - Street 1:8 CEDAR CT
Practice Address - Street 2:
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937-2246
Practice Address - Country:US
Practice Address - Phone:631-903-7996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022387-12251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports