Individual
MICHAEL TYLER WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
ATC, LAT
Contact information
Practice address
411 CENTRAL METHODIST SQ, FAYETTE, MO 65248-1104
(636) 577-5062
Mailing address
411 CENTRAL METHODIST SQ, FAYETTE, MO 65248-1104
(636) 577-5062
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
2016023484
MO
Other
Enumeration date
08/03/2016
Last updated
08/03/2016
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