Provider Demographics
NPI:1063685592
Name:WILSON, TED LEWIS (PHYSICIANS ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:TED
Middle Name:LEWIS
Last Name:WILSON
Suffix:
Gender:M
Credentials:PHYSICIANS ASSISTANT
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Mailing Address - Street 1:7210 WINDSOR BLVD
Mailing Address - Street 2:RUTHERFORD BUSINESS CENTER
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2633
Mailing Address - Country:US
Mailing Address - Phone:410-597-7438
Mailing Address - Fax:410-597-7722
Practice Address - Street 1:7210 WINDSOR BLVD
Practice Address - Street 2:RUTHERFORD BUSINESS CENTER
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21244-2633
Practice Address - Country:US
Practice Address - Phone:410-597-7438
Practice Address - Fax:410-597-7722
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDC00001109363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical