Individual
MR. MARK PAUL WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CRPA PROVISIONAL
Contact information
Practice address
98 PINE NECK AVE, E PATCHOGUE, NY 11772-5730
(631) 901-2767
Mailing address
98 PINE NECK AVE, E PATCHOGUE, NY 11772-5730
(631) 901-2767
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
—
NY
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
02/06/2025
Last updated
02/21/2025
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