Provider Demographics
NPI:1063703684
Name:WILSON, ABIGAIL
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 1ST AVE
Mailing Address - Street 2:APT 410
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4742
Mailing Address - Country:US
Mailing Address - Phone:610-724-3519
Mailing Address - Fax:
Practice Address - Street 1:520 E 70TH ST FL 4
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-9800
Practice Address - Country:US
Practice Address - Phone:212-746-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-30
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY562785163W00000X
NY305594363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse