=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225075609
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAMELA J VANDERWALL MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2006
-----------------------------------------------------
Last Update Date | 10/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2845 GREENBRIER RD
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54311-6519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-288-4160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11516 N PORT WASHINGTON RD STE 107
-----------------------------------------------------
City | MEQUON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53092-3478
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-241-5040
-----------------------------------------------------
Fax | 262-241-5261
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number | 29877
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------