Provider Demographics
NPI:1760429138
Name:WYMORE, PAMELA J (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:J
Last Name:WYMORE
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 1:166 4TH STREET E
Mailing Address - Street 2:
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101
Mailing Address - Country:US
Mailing Address - Phone:651-292-2000
Mailing Address - Fax:651-292-2136
Practice Address - Street 1:166 4TH STREET E
Practice Address - Street 2:
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101
Practice Address - Country:US
Practice Address - Phone:651-292-2000
Practice Address - Fax:651-292-2136
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN375712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00201776OtherRAILROAD MEDICARE MN
MN1030863OtherPREFERRED ONE
MN1603279OtherMEDICA
MN089807400Medicaid
MN502T0WYOtherBLUE CROSS
MN2182694OtherAMERICA'S PPO
MN502T1WYOtherBLUE CROSS
WI34234600Medicaid
MNHP43094OtherHEALTHPARTNERS
IA0582015Medicaid
MN2182694OtherAMERICA'S PPO
MN300003498Medicare PIN
WI003756135Medicare PIN
MNP00201776OtherRAILROAD MEDICARE MN
IA0582015Medicaid
WI34234600Medicaid