Provider Demographics
NPI:1972554814
Name:WILSON, CHRISTOPHER ALEXANDER (PT)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:ALEXANDER
Last Name:WILSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12551 OLD GLENN HWY
Mailing Address - Street 2:STE E
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7590
Mailing Address - Country:US
Mailing Address - Phone:907-694-5515
Mailing Address - Fax:907-694-5575
Practice Address - Street 1:12551 OLD GLENN HWY
Practice Address - Street 2:STE E
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7590
Practice Address - Country:US
Practice Address - Phone:907-694-5515
Practice Address - Fax:907-694-5575
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1007225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT1007Medicaid
AK153147Medicare ID - Type UnspecifiedPROVIDER NUMBER