Provider Demographics
NPI:1376899351
Name:WILSON, THERESA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
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 1:122 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4512
Mailing Address - Country:US
Mailing Address - Phone:301-498-5990
Mailing Address - Fax:301-498-6576
Practice Address - Street 1:8118 GOOD LUCK RD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3574
Practice Address - Country:US
Practice Address - Phone:301-552-8118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001801363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical