Basic Information
| Provider Information | |||||||||
| NPI: | 1194113704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKINSON | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | EVERETT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 73993 | ||||||||
| Address2: | |||||||||
| City: | SAN CLEMENTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926730134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493666785 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 901 CALLE AMANECER | ||||||||
| Address2: | |||||||||
| City: | SAN CLEMENTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926736278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493666785 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2015 | ||||||||
| LastUpdateDate: | 01/05/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | AT 10466 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.