Healthcare Provider Details

I. General information

NPI: 1407004872
Provider Name (Legal Business Name): PAMELA WILBANKS BUNTING DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 BOWLES AVE STE G10
FENTON MO
63026-2387
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 636-496-5453
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number2009007650
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2009007650
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: