Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0200X | Occupational Therapist - Pediatrics | 102973 | MN |
NPI | 1043468671 |
---|---|
Provider Name | Martin Wilson |
First Address | Edina, MN 55435-4762 |
Second Address | Edina, MN 55435-4762 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/09/2008 |
Last Update Date | 16/06/2018 |