Individual
DR. MARY M WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
11665 PONDVIEW CT, CHAMPLIN, MN 55316-2629
(763) 421-9387
(763) 421-9387
Mailing address
11665 PONDVIEW CT, CHAMPLIN, MN 55316-2629
(763) 421-9387
(763) 421-9387
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
33356
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
33356
MN MEDICAL LICENSE
—
05
—
938500200
—
MN
Enumeration date
03/18/2006
Last updated
11/16/2010
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