Basic Information
| Provider Information | |||||||||
| NPI: | 1285021071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | OPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7208 HARDY DR | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787572207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5126566143 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16020 PARK VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786813573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124776341 | ||||||||
| FaxNumber: | 5124771959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2015 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | 913 | N | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant | 246ZS0410X | 913 | N | 246ZX2200X | 913 | Y | 193400000X SINGLE SPECIALTY GROUP |
ID Information
| ID | Type | State | Issuer | Description | #913 | 01 | ORTHOPEDIC PHYSICIAN ASSISTANTS | OTHER |