Provider Demographics
NPI:1255887568
Name:WILSON, JAMIE III (PTA)
Entity type:Individual
Prefix:MR
First Name:JAMIE
Middle Name:
Last Name:WILSON
Suffix:III
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 52ND AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-4694
Mailing Address - Country:US
Mailing Address - Phone:727-488-8944
Mailing Address - Fax:
Practice Address - Street 1:4300 52ND AVE S
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-4694
Practice Address - Country:US
Practice Address - Phone:727-488-8944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-27
Last Update Date:2016-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA9303225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant