Provider Demographics
NPI:1861084287
Name:WILSON, REGINA (ATC)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 GERHARD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1632
Mailing Address - Country:US
Mailing Address - Phone:215-756-3534
Mailing Address - Fax:
Practice Address - Street 1:514 GERHARD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1632
Practice Address - Country:US
Practice Address - Phone:215-756-3534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-08
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer