Basic Information
| Provider Information | |||||||||
| NPI: | 1083692842 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4021 BALMORAL DR SW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358016403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565392741 | ||||||||
| FaxNumber: | 2565392775 | ||||||||
| Practice Location | |||||||||
| Address1: | 4021 BALMORAL DR SW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358016403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565392741 | ||||||||
| FaxNumber: | 2565392775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2006 | ||||||||
| LastUpdateDate: | 12/05/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 21559 | AL | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 51077860 | 01 | AL | BCBS OF AL | OTHER |