Provider Demographics
NPI:1871226761
Name:WILSON, KAITLIN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MARIE
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 1:1306 CONCOURSE DR STE 201
Mailing Address - Street 2:
Mailing Address - City:LINTHICUM HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:21090-1033
Mailing Address - Country:US
Mailing Address - Phone:813-882-9986
Mailing Address - Fax:813-341-3259
Practice Address - Street 1:417 VANCE ST FL 2
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-4001
Practice Address - Country:US
Practice Address - Phone:910-251-9944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
NC0010-12462363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical