Individual
LARRY C MACK-WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.A.
Contact information
Practice address
1850 TOWN CENTER PKWY, RESTON, VA 20190-3219
(703) 689-9039
(703) 689-9109
Mailing address
20010 CENTURY BLVD, SUITE 200, GERMANTOWN, MD 20874-1115
(240) 686-2300
(240) 686-2330
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
0110003693
VA
Other
Enumeration date
10/04/2011
Last updated
10/04/2011
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