Provider Demographics
NPI:1144988395
Name:WILSON, PHILIP MATTHEW (MS, RCEP, CCRP)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:MATTHEW
Last Name:WILSON
Suffix:
Gender:M
Credentials:MS, RCEP, CCRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 N E ST STE 103
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-6337
Mailing Address - Country:US
Mailing Address - Phone:850-908-2235
Mailing Address - Fax:
Practice Address - Street 1:1717 NORTH E STREET
Practice Address - Street 2:TOWER 1, SUITE 1
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501
Practice Address - Country:US
Practice Address - Phone:850-908-2235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-06
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1068726224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise PhysiologistGroup - Single Specialty