Healthcare Provider Details

I. General information

NPI: 1013546274
Provider Name (Legal Business Name): CATHERINE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 WARWICK BLVD STE 110
NEWPORT NEWS VA
23601-2344
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD STE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 757-534-9988
  • Fax:
Mailing address:
  • Phone: 757-316-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0101275294
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: