Provider Demographics
NPI:1811471444
Name:WILSON, CASEY (ATC)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S MADISON AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-1005
Mailing Address - Country:US
Mailing Address - Phone:253-988-4550
Mailing Address - Fax:
Practice Address - Street 1:9040A JACKSON AVE UNIT A202
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98431-1235
Practice Address - Country:US
Practice Address - Phone:253-988-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000397062255A2300X
CAY5456290390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer