Basic Information
| Provider Information | |||||||||
| NPI: | 1265006712 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8337 BARTON AVE NW | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553132749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7636881987 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14451 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | BURNSVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553065708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529938700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2021 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.