Provider Demographics
NPI:1770397853
Name:WILSON, MARK PAUL (CRPA PROVISIONAL)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:PAUL
Last Name:WILSON
Suffix:
Gender:
Credentials:CRPA PROVISIONAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 PINE NECK AVE
Mailing Address - Street 2:
Mailing Address - City:E PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-5730
Mailing Address - Country:US
Mailing Address - Phone:631-901-2767
Mailing Address - Fax:
Practice Address - Street 1:98 PINE NECK AVE
Practice Address - Street 2:
Practice Address - City:E PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-5730
Practice Address - Country:US
Practice Address - Phone:631-901-2767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-06
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program