Provider Demographics
NPI:1083610430
Name:WILSON, PAMELA DENISE (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:DENISE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:DENISE
Other - Last Name:BOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2906 S 20TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3732
Mailing Address - Country:US
Mailing Address - Phone:414-672-1353
Mailing Address - Fax:414-672-4265
Practice Address - Street 1:2906 S 20TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3732
Practice Address - Country:US
Practice Address - Phone:414-672-1353
Practice Address - Fax:414-672-4265
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42350207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34064100Medicaid
WI461310335OtherHUMANA
WI7426373OtherAETNA
WI8130732OtherCIGNA
WIBB7186807OtherDEA
WI461310335OtherHUMANA
WIH32473Medicare UPIN
WI521805Medicare Oscar/Certification
WI0062:01545Medicare PIN