Provider Demographics
NPI:1467512608
Name:WILSON, HETTIE TABITHA (PA)
Entity Type:Individual
Prefix:
First Name:HETTIE
Middle Name:TABITHA
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:
Practice Address - Street 1:20010 CENTURY BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-1115
Practice Address - Country:US
Practice Address - Phone:240-686-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA0365363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y8829OtherBCBSTX
TX8N4694OtherBLUE CROSS BLUE SHIELD
TXP00227237OtherRAILROAD MEDICARE
TX182578802Medicaid
Q05393Medicare UPIN
8L3277Medicare PIN