Provider Demographics
NPI:1457405615
Name:WILSON, ELIZABETH T (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:T
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 SOLAREX COURT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:56 THOMAS JOHNSON DR
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4599
Practice Address - Country:US
Practice Address - Phone:301-694-3111
Practice Address - Fax:301-694-8626
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002912363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD926580503Medicaid
MD926580505Medicaid
MD926580503Medicaid
MD238413ZCSVMedicare PIN
MD926580505Medicaid