Provider Demographics
NPI:1699185819
Name:FABIAN WILSON, NOELLE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:NOELLE
Middle Name:MARIE
Last Name:FABIAN WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NOELLE
Other - Middle Name:MARIE
Other - Last Name:FABIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2700 SNELLNIG AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:512-324-8355
Mailing Address - Fax:
Practice Address - Street 1:333 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-235-4370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-28
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10050054207L00000X
MN63798207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology