Provider Demographics
NPI:1003112186
Name:WILSON, PAMELA G (LMP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:G
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14004 SE 202ND ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98042-3017
Mailing Address - Country:US
Mailing Address - Phone:253-691-0611
Mailing Address - Fax:
Practice Address - Street 1:14004 SE 202ND ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98042-3017
Practice Address - Country:US
Practice Address - Phone:253-691-0611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00023593171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor