Provider Demographics
NPI:1427028166
Name:WILSON, FITZPATRICK CHRISPIN (MD)
Entity Type:Individual
Prefix:
First Name:FITZPATRICK
Middle Name:CHRISPIN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9601 PULASKI PARK DR
Mailing Address - Street 2:SUITE 416
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-1409
Mailing Address - Country:US
Mailing Address - Phone:410-933-5678
Mailing Address - Fax:410-933-3923
Practice Address - Street 1:9601 PULASKI PARK DR
Practice Address - Street 2:SUITE 416
Practice Address - City:MIDDLE RIVER
Practice Address - State:MD
Practice Address - Zip Code:21220-1409
Practice Address - Country:US
Practice Address - Phone:410-933-5678
Practice Address - Fax:410-933-3923
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0078812208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP01005675Medicare PIN
VA1427028166Medicaid
VAVV4111AMedicare PIN