Provider Demographics
NPI:1114181914
Name:WILSON, MONIQUE JUSTINE (MD)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:JUSTINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:JUSTINE
Other - Last Name:VANAMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:15055 LOS GATOS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2056
Practice Address - Country:US
Practice Address - Phone:408-356-1000
Practice Address - Fax:408-356-1125
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA143347207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA143347OtherMEDICAL LICENSE