1588353742 NPI number — MR. JONATHAN WESLEY WILSON DPT

Table of content: MR. JONATHAN WESLEY WILSON DPT (NPI 1588353742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588353742 NPI number — MR. JONATHAN WESLEY WILSON DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
JONATHAN
Provider Middle Name:
WESLEY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588353742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1077 WOODMONT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEADVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16335-2859
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-795-0287
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11277 VERNON PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEADVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16335-3717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-333-5214
Provider Business Practice Location Address Fax Number:
814-333-1482
Provider Enumeration Date:
05/03/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT030657 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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