Provider Demographics
NPI:1730423666
Name:WILSON, WALLACE (MSPT)
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 SESAME ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-6647
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 SESAME ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-6647
Practice Address - Country:US
Practice Address - Phone:907-561-2260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1625225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist