Provider Demographics
NPI:1528739349
Name:WILSON, EDWINA GAUTAM
Entity type:Individual
Prefix:
First Name:EDWINA GAUTAM
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 FORT WASHINGTON AVE APT 34
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-4776
Mailing Address - Country:US
Mailing Address - Phone:312-825-7937
Mailing Address - Fax:914-294-0079
Practice Address - Street 1:3163 BAINBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-3907
Practice Address - Country:US
Practice Address - Phone:914-234-8543
Practice Address - Fax:914-294-0079
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047589225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist