Provider Demographics
NPI:1235413667
Name:MACK-WILSON, LARRY C (PA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:C
Last Name:MACK-WILSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:20010 CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-1115
Mailing Address - Country:US
Mailing Address - Phone:240-686-2300
Mailing Address - Fax:240-686-2330
Practice Address - Street 1:1850 TOWN CENTER PKWY
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3219
Practice Address - Country:US
Practice Address - Phone:703-689-9039
Practice Address - Fax:703-689-9109
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110003693363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical