Provider Demographics
NPI:1245947522
Name:WILSON, GABRIEL (CRNP-FAMILY)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:CRNP-FAMILY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6131 SHADY SIDE RD
Mailing Address - Street 2:
Mailing Address - City:SHADY SIDE
Mailing Address - State:MD
Mailing Address - Zip Code:20764-9504
Mailing Address - Country:US
Mailing Address - Phone:410-867-4700
Mailing Address - Fax:
Practice Address - Street 1:134 OWENSVILLE RD
Practice Address - Street 2:
Practice Address - City:WEST RIVER
Practice Address - State:MD
Practice Address - Zip Code:20778-9702
Practice Address - Country:US
Practice Address - Phone:410-867-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR225305207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine