Provider Demographics
NPI:1639336357
Name:WILSON, SEAN ALAN (PT)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:ALAN
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 1:325 MDG
Mailing Address - Street 2:340 MAGNOLIA CIRCLE
Mailing Address - City:TYNDALL AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32403-5604
Mailing Address - Country:US
Mailing Address - Phone:336-598-2472
Mailing Address - Fax:
Practice Address - Street 1:325 MDG
Practice Address - Street 2:340 MAGNOLIA CIRCLE
Practice Address - City:TYNDALL AFB
Practice Address - State:FL
Practice Address - Zip Code:32403-5604
Practice Address - Country:US
Practice Address - Phone:336-598-2472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-20
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11264225100000X
NC11624225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty