Healthcare Provider Details

I. General information

NPI: 1528906443
Provider Name (Legal Business Name): BENJAMIN WILSON CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N BROADWAY ST
BALTIMORE MD
21287-0019
US

IV. Provider business mailing address

949 BUTTONWOOD TRL
CROWNSVILLE MD
21032-1846
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-5222
  • Fax:
Mailing address:
  • Phone: 703-300-0630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR245378
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: