Healthcare Provider Details

I. General information

NPI: 1235413667
Provider Name (Legal Business Name): LARRY C MACK-WILSON P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2011
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 TOWN CENTER PKWY
RESTON VA
20190-3219
US

IV. Provider business mailing address

20010 CENTURY BLVD SUITE 200
GERMANTOWN MD
20874-1115
US

V. Phone/Fax

Practice location:
  • Phone: 703-689-9039
  • Fax: 703-689-9109
Mailing address:
  • Phone: 240-686-2300
  • Fax: 240-686-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110003693
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: