Healthcare Provider Details

I. General information

NPI: 1194151316
Provider Name (Legal Business Name): WILTON L WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4134 E JOPPA RD SUITE 202
BALTIMORE MD
21236-2284
US

IV. Provider business mailing address

1900 WALTMAN RD
EDGEWOOD MD
21040-2338
US

V. Phone/Fax

Practice location:
  • Phone: 410-248-9800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR156587
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: