Provider Demographics
NPI:1134834393
Name:WILSON, LEWIS (CRNP-PMH)
Entity type:Individual
Prefix:MR
First Name:LEWIS
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:CRNP-PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8306 LARCHWOOD ST
Mailing Address - Street 2:
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-3409
Mailing Address - Country:US
Mailing Address - Phone:301-741-2232
Mailing Address - Fax:
Practice Address - Street 1:8306 LARCHWOOD ST
Practice Address - Street 2:
Practice Address - City:NEW CARROLLTON
Practice Address - State:MD
Practice Address - Zip Code:20784-3409
Practice Address - Country:US
Practice Address - Phone:301-741-2232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR169763363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health