Healthcare Provider Details

I. General information

NPI: 1790759215
Provider Name (Legal Business Name): JULIE P. WILSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 10/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 AMERICAN AVE
WAUKESHA WI
53188-5031
US

IV. Provider business mailing address

N17W24100 RIVERWOOD DR SUITE 250
WAUKESHA WI
53188-1177
US

V. Phone/Fax

Practice location:
  • Phone: 262-928-8200
  • Fax: 262-928-8699
Mailing address:
  • Phone: 262-928-4100
  • Fax: 262-928-5835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number39064
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number39064
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: