Provider Demographics
NPI:1396009247
Name:WILMOT-DESOUZA, NANA A (MD)
Entity Type:Individual
Prefix:DR
First Name:NANA
Middle Name:A
Last Name:WILMOT-DESOUZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NANA
Other - Middle Name:
Other - Last Name:WILMOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:15650 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7283
Mailing Address - Country:US
Mailing Address - Phone:952-997-4122
Mailing Address - Fax:
Practice Address - Street 1:15650 CEDAR AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7283
Practice Address - Country:US
Practice Address - Phone:952-997-4122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN59846207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine