Basic Information
| Provider Information | |||||||||
| NPI: | 1487790150 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | VICTORIA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK ROAD | ||||||||
| Address2: | EXECUTIVE PLAZA 1, SUITE 501 | ||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107878315 | ||||||||
| FaxNumber: | 4107878316 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 CRAIN HWY S | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | GLEN BURNIE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210615577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107878315 | ||||||||
| FaxNumber: | 4107878316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | C0003276 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.