Provider Demographics
NPI:1003305533
Name:DEWILDE, PAMELA MARIE (DO (AS OF 6/17/18))
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:MARIE
Last Name:DEWILDE
Suffix:
Gender:F
Credentials:DO (AS OF 6/17/18)
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:MARIE
Other - Last Name:KELSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1464 JEFFERSON ST N
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-1380
Mailing Address - Country:US
Mailing Address - Phone:304-645-3220
Mailing Address - Fax:844-479-4545
Practice Address - Street 1:1464 JEFFERSON ST N
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-1380
Practice Address - Country:US
Practice Address - Phone:304-645-3220
Practice Address - Fax:844-479-4545
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3647204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM