Provider Demographics
NPI:1083692842
Name:WILSON, PATRICIA J (MD)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4021 BALMORAL DR SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6403
Mailing Address - Country:US
Mailing Address - Phone:256-539-2741
Mailing Address - Fax:256-539-2775
Practice Address - Street 1:4021 BALMORAL DR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6403
Practice Address - Country:US
Practice Address - Phone:256-539-2741
Practice Address - Fax:256-539-2775
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21559207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51077860OtherBCBS OF AL
AL00007860Medicare Oscar/Certification
G19414Medicare UPIN