1114181914 NPI number — MONIQUE JUSTINE WILSON MD

Table of content: MONIQUE JUSTINE WILSON MD (NPI 1114181914)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114181914 NPI number — MONIQUE JUSTINE WILSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
MONIQUE
Provider Middle Name:
JUSTINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VANAMAN
Provider Other First Name:
MONIQUE
Provider Other Middle Name:
JUSTINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114181914
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
801 YORK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANITOWOC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54220-4630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-663-9008
Provider Business Mailing Address Fax Number:
920-684-1439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15055 LOS GATOS BLVD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS GATOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95032-2056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-356-1000
Provider Business Practice Location Address Fax Number:
408-356-1125
Provider Enumeration Date:
07/11/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  A143347 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)