Provider Demographics
NPI:1891739900
Name:WILSON, PAMELA ANNE (DO FACOP)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:ANNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO FACOP
Other - Prefix:
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Mailing Address - Street 1:100 SOUTH ST
Mailing Address - Street 2:MEDICAL ARTS BUILDING, STE 207
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-4051
Mailing Address - Country:US
Mailing Address - Phone:508-765-9700
Mailing Address - Fax:508-765-9704
Practice Address - Street 1:100 SOUTH ST
Practice Address - Street 2:MEDICAL ARTS BUILDING, STE 207
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-4051
Practice Address - Country:US
Practice Address - Phone:508-765-9700
Practice Address - Fax:508-765-9704
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA72206208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3066843Medicaid
MAE56591Medicare UPIN