Provider Demographics
NPI:1215003546
Name:WILSON, ELEANOR ANNE (DPM)
Entity Type:Individual
Prefix:DR
First Name:ELEANOR
Middle Name:ANNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNIT 6 W
Mailing Address - Street 2:KAISER PERMANENTE MID ATL PERM MED GRP PC ATTN T.BROOKS
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:6501 LOISDALE COURT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-1885
Practice Address - Country:US
Practice Address - Phone:703-922-1034
Practice Address - Fax:703-922-1628
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01174213E00000X
VA0103000949213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U43154Medicare UPIN
010215M92Medicare ID - Type Unspecified