Healthcare Provider Details

I. General information

NPI: 1942648183
Provider Name (Legal Business Name): ROSE WILSON A.A.-C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 06/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 IRVING ST NW G2-67
WASHINGTON DC
20010-3017
US

IV. Provider business mailing address

20944 GLENBURN TER
ASHBURN VA
20147-6491
US

V. Phone/Fax

Practice location:
  • Phone: 202-877-7500
  • Fax:
Mailing address:
  • Phone: 703-507-8193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA000036
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: