Provider Demographics
NPI:1639528748
Name:WILSON, LINDA (FMP)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:FMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-4015
Mailing Address - Country:US
Mailing Address - Phone:215-471-2904
Mailing Address - Fax:
Practice Address - Street 1:440 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-4015
Practice Address - Country:US
Practice Address - Phone:215-471-2904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP008244364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health