Provider Demographics
NPI:1225075609
Name:VANDERWALL, PAMELA J (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:J
Last Name:VANDERWALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:VANDERWALL-LOIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11516 N PORT WASHINGTON RD STE 107
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3478
Mailing Address - Country:US
Mailing Address - Phone:262-241-5040
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-4160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI298772085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31627700Medicaid
WI000407755Medicare ID - Type Unspecified
E93987Medicare UPIN