Provider Demographics
NPI:1760825731
Name:WILSON, MARY ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY ELLEN
Other - Middle Name:
Other - Last Name:LISMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:3025 MARKET ST
Practice Address - Street 2:SUITE B
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-4518
Practice Address - Country:US
Practice Address - Phone:717-691-1212
Practice Address - Fax:717-691-5354
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD458058207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program