Provider Demographics
NPI:1639903792
Name:WILSON, JOHN A (DPT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 62
Mailing Address - Street 2:
Mailing Address - City:CAPE MAY COURT HOUSE
Mailing Address - State:NJ
Mailing Address - Zip Code:08210-0062
Mailing Address - Country:US
Mailing Address - Phone:215-584-0119
Mailing Address - Fax:
Practice Address - Street 1:215 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CAPE MAY COURT HOUSE
Practice Address - State:NJ
Practice Address - Zip Code:08210-2192
Practice Address - Country:US
Practice Address - Phone:215-584-0119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02282400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist