Provider Demographics
NPI:1689899981
Name:WILSON, HEATHER LEE (DPM)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8221 OLD COURTHOUSE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3839
Mailing Address - Country:US
Mailing Address - Phone:703-734-1311
Mailing Address - Fax:703-734-9090
Practice Address - Street 1:8221 OLD COURTHOUSE RD STE 102
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3839
Practice Address - Country:US
Practice Address - Phone:703-734-1311
Practice Address - Fax:703-734-9090
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300729213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU76405Medicare UPIN