Provider Demographics
NPI:1417974262
Name:WIBLE, PAMELA LAINE (MD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:LAINE
Last Name:WIBLE
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 1:3575 DONALD ST STE 220
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-4759
Mailing Address - Country:US
Mailing Address - Phone:541-345-2437
Mailing Address - Fax:
Practice Address - Street 1:3575 DONALD ST
Practice Address - Street 2:220
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-4753
Practice Address - Country:US
Practice Address - Phone:541-345-2437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR19836OtherOR STATE MEDICAL LICENSE
131788Medicare ID - Type UnspecifiedMEDICARE BILLING #
OR19836OtherOR STATE MEDICAL LICENSE