Provider Demographics
NPI:1053428698
Name:WILSON, LUCAS BO (MPT)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:BO
Last Name:WILSON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 REDCLIFF DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-0157
Mailing Address - Country:US
Mailing Address - Phone:530-246-2467
Mailing Address - Fax:
Practice Address - Street 1:405 REDCLIFF DR
Practice Address - Street 2:SUITE 100
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-0157
Practice Address - Country:US
Practice Address - Phone:530-246-2467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT30275225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist