Basic Information
| Provider Information | |||||||||
| NPI: | 1760429138 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYMORE | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 166 4TH STREET E | ||||||||
| Address2: | |||||||||
| City: | ST. PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512922000 | ||||||||
| FaxNumber: | 6512922136 | ||||||||
| Practice Location | |||||||||
| Address1: | 166 4TH STREET E | ||||||||
| Address2: | |||||||||
| City: | ST. PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512922000 | ||||||||
| FaxNumber: | 6512922136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 37571 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00201776 | 01 | MN | RAILROAD MEDICARE MN | OTHER | 1030863 | 01 | MN | PREFERRED ONE | OTHER | 1603279 | 01 | MN | MEDICA | OTHER | 089807400 | 05 | MN | MEDICAID | 502T0WY | 01 | MN | BLUE CROSS | OTHER | 2182694 | 01 | MN | AMERICA'S PPO | OTHER | 502T1WY | 01 | MN | BLUE CROSS | OTHER | 34234600 | 05 | WI | MEDICAID | HP43094 | 01 | MN | HEALTHPARTNERS | OTHER |