Provider Demographics
NPI:1033232830
Name:WILSON, PAMELA EILEEN (DC)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:EILEEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 MAPLE AVE
Mailing Address - Street 2:SUITE 7A
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-1734
Mailing Address - Country:US
Mailing Address - Phone:732-842-7004
Mailing Address - Fax:732-842-8799
Practice Address - Street 1:130 MAPLE AVE
Practice Address - Street 2:SUITE 7A
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1734
Practice Address - Country:US
Practice Address - Phone:732-842-7004
Practice Address - Fax:732-842-8799
Is Sole Proprietor?:No
Enumeration Date:2007-04-08
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3851111NR0400X
NY011256111NR0400X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP413708OtherOXFORD INS ID#
NJU24383Medicare UPIN
NJWI697608Medicare ID - Type Unspecified