Provider Demographics
NPI:1962629998
Name:WILSON, ANGELA T (PT)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:T
Last Name:WILSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:ANGELA
Other - Middle Name:T
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPTA
Mailing Address - Street 1:1010 N JESSE JAMES RD
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64024-1202
Mailing Address - Country:US
Mailing Address - Phone:620-340-5085
Mailing Address - Fax:
Practice Address - Street 1:1010 N JESSE JAMES RD
Practice Address - Street 2:
Practice Address - City:EXCELSIOR SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64024-1202
Practice Address - Country:US
Practice Address - Phone:620-340-5085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-02529225100000X
MO2009027345225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist