Provider Demographics
NPI:1164081915
Name:WILSON, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8110 MAPLE LAWN BLVD STE 235
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MD
Mailing Address - Zip Code:20759-2694
Mailing Address - Country:US
Mailing Address - Phone:013-408-3393
Mailing Address - Fax:
Practice Address - Street 1:10521 ROSEHAVEN ST STE LL100
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2877
Practice Address - Country:US
Practice Address - Phone:703-281-5000
Practice Address - Fax:703-255-0765
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1021762363LW0102X
VA0024177383363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health