Individual
KATHERINE WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
ATC
Contact information
Practice address
4318 SPYRES WAY, MODESTO, CA 95356-9259
(209) 576-0710
Mailing address
310 HACKBERRY AVE, MODESTO, CA 95354-0508
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
ZZZ03337Z
MEDICARE
—
Enumeration date
01/16/2015
Last updated
01/16/2015
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