Individual
HETTIE TABITHA WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
20010 CENTURY BLVD, SUITE 200, GERMANTOWN, MD 20874-1115
(240) 686-2300
Mailing address
20010 CENTURY BLVD, SUITE 200, GERMANTOWN, MD 20874-1115
(240) 686-2300
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA0365
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
182578802
—
TX
01
—
8N4694
BLUE CROSS BLUE SHIELD
TX
01
—
8Y8829
BCBSTX
TX
01
—
P00227237
RAILROAD MEDICARE
TX
Enumeration date
12/11/2006
Last updated
10/11/2013
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