Basic Information
Provider Information
NPI: 1003004193
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WILSON
FirstName: ELIZABETH
MiddleName: AMY
NamePrefix:  
NameSuffix:  
Credential: ATC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3355 LOMA LINDA DR
Address2:  
City: EUGENE
State: OR
PostalCode: 974052791
CountryCode: US
TelephoneNumber: 7173439501
FaxNumber:  
Practice Location
Address1: 1240 UNIVERSITY OF OREGON
Address2: 122 ESSLINGER
City: EUGENE
State: OR
PostalCode: 974031205
CountryCode: US
TelephoneNumber: 5413464107
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/15/2007
LastUpdateDate: 10/15/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2255A2300X ORY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer

No ID Information.


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