Provider Demographics
NPI:1023552817
Name:WILSON, BEVERLY N (PA-C)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:N
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12038 OCEAN GATEWAY
Mailing Address - Street 2:UNIT 1
Mailing Address - City:OCEAN CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21842
Mailing Address - Country:US
Mailing Address - Phone:410-390-3341
Mailing Address - Fax:410-390-3618
Practice Address - Street 1:12038 OCEAN GATEWAY
Practice Address - Street 2:UNIT 1
Practice Address - City:OCEAN CITY
Practice Address - State:MD
Practice Address - Zip Code:21842
Practice Address - Country:US
Practice Address - Phone:410-390-3341
Practice Address - Fax:410-390-3618
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0006301363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC0006301OtherMEDICAL LICENSE