MEDICARE: MONIQUE JUSTINE WILSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	A143347	CA

General Provider Information

NPI Number	:	1114181914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONIQUE JUSTINE WILSON MD

Provider Business Mailing Address
First Line	:	801 YORK ST
Second Line	:
City	:	MANITOWOC
State	:	WI
Zip	:	54220-4630
Country	:	US
Telephone Number	:	920-663-9008
Fax Number	:	920-684-1439

Provider Business Practice Location Address
First Line	:	15055 LOS GATOS BLVD STE 100
Second Line	:
City	:	LOS GATOS
State	:	CA
Zip	:	95032-2056
Country	:	US
Telephone Number	:	408-356-1000
Fax Number	:	408-356-1125

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2008
Last Update Date	:	07/08/2022

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