Provider Demographics
NPI:1265766414
Name:WILSON, PAMELA JILL (RD)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:JILL
Last Name:WILSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 NORRIS CANYON RD
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-5400
Mailing Address - Country:US
Mailing Address - Phone:925-275-8425
Mailing Address - Fax:925-275-8394
Practice Address - Street 1:6001 NORRIS CANYON RD
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-5400
Practice Address - Country:US
Practice Address - Phone:925-275-8425
Practice Address - Fax:925-275-8394
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA719850133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered