Basic Information
| Provider Information | |||||||||
| NPI: | 1427230663 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 APEX DR | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622491282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184410482 | ||||||||
| FaxNumber: | 6184410482 | ||||||||
| Practice Location | |||||||||
| Address1: | 790 N. HWY 67 | ||||||||
| Address2: | |||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630315108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149721442 | ||||||||
| FaxNumber: | 3149721533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2007 | ||||||||
| LastUpdateDate: | 10/21/2015 | ||||||||
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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 | 208100000X | 070016087 | IL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 08220357 | 01 | IL | BCBS GROUP# | OTHER |