Individual
KYLAN WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CERTIFIED PEDORTHIST
Contact information
Practice address
110 E TWOHIG AVE, SAN ANGELO, TX 76903-5916
(325) 658-1511
(325) 481-2166
Mailing address
PO BOX 22000, SAN ANGELO, TX 76902-7200
(325) 658-1511
(325) 481-2166
Taxonomy
Speciality
Code
Description
License number
State
222Z00000X
Orthotist
Primary
4075
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CPED4075
CERTIFICATION
TX
Enumeration date
05/13/2014
Last updated
05/13/2014
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