Basic Information
| Provider Information | |||||||||
| NPI: | 1043896889 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSIE | ||||||||
| FirstName: | COLE | ||||||||
| MiddleName: | JORDAN | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2437 N PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927061610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146048576 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18785 BROOKHURST ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927087300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6573014967 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2021 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 51134 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.