Provider Demographics
NPI:1801156286
Name:SY, WILSON SON (RPT)
Entity type:Individual
Prefix:MR
First Name:WILSON
Middle Name:SON
Last Name:SY
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13139 FOX GLOVE ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-4718
Mailing Address - Country:US
Mailing Address - Phone:407-877-0710
Mailing Address - Fax:
Practice Address - Street 1:13139 FOX GLOVE ST
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-4718
Practice Address - Country:US
Practice Address - Phone:407-877-0710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-20
Last Update Date:2012-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17111225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist