Provider Demographics
NPI:1174934186
Name:WILSON, KYLAN (CERTIFIED PEDORTHIST)
Entity type:Individual
Prefix:
First Name:KYLAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:CERTIFIED PEDORTHIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22000
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-7200
Mailing Address - Country:US
Mailing Address - Phone:325-658-1511
Mailing Address - Fax:325-481-2166
Practice Address - Street 1:110 E TWOHIG AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-5916
Practice Address - Country:US
Practice Address - Phone:325-658-1511
Practice Address - Fax:325-481-2166
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4075222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCPED4075OtherCERTIFICATION
TXCPED4075OtherCERTIFICATION