Provider Demographics
NPI:1992764054
Name:WILSON, MARY M (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:MARGARET
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11665 PONDVIEW CT
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-2629
Mailing Address - Country:US
Mailing Address - Phone:763-421-9387
Mailing Address - Fax:763-421-9387
Practice Address - Street 1:11665 PONDVIEW CT
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-2629
Practice Address - Country:US
Practice Address - Phone:763-421-9387
Practice Address - Fax:763-421-9387
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-18
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33356207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
33356OtherMN MEDICAL LICENSE
MN938500200Medicaid
33356OtherMN MEDICAL LICENSE
MN938500200Medicaid