Provider Demographics
NPI:1891080719
Name:WILSON, BRENDA A (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:A
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 1:1086 W KING RD
Mailing Address - Street 2:CHESTNUT 213
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-1975
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3601 A ST
Practice Address - Street 2:ERIE AVE & FRONT ST
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-1043
Practice Address - Country:US
Practice Address - Phone:215-427-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT180578208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics