Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LA2100X | Nurse Practitioner - Acute Care | R115362 | MD |
Y | 363LC0200X | Nurse Practitioner - Critical Care Medicine | R115362 | MD |
NPI | 1487828885 |
---|---|
Provider Name | Tracey Wilson |
First Address | Baltimore, MD 21264-4442 |
Second Address | Baltimore, MD 21201-1504 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/04/2008 |
Last Update Date | 12/08/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
419033500 | (05) | MD |
960542-01 & 02 | BLUE CROSS/BLUE SHIELD (01) | MD |
S062-0375 | BLUE SHIELD REGIONAL (01) | MD |