Provider Demographics
NPI:1326025123
Name:WILSON, PANCHETA B (MD)
Entity Type:Individual
Prefix:
First Name:PANCHETA
Middle Name:B
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7798 NW 55TH PL
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-2058
Mailing Address - Country:US
Mailing Address - Phone:954-344-2793
Mailing Address - Fax:
Practice Address - Street 1:1505 UNIVERSITY DR
Practice Address - Street 2:SUITE 402
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071
Practice Address - Country:US
Practice Address - Phone:954-344-2793
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045995173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine