1326269739 NPI number — MR. JACK ANTHONY WILDER PT

Table of content: MR. JACK ANTHONY WILDER PT (NPI 1326269739)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326269739 NPI number — MR. JACK ANTHONY WILDER PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILDER
Provider First Name:
JACK
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326269739
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4701 77TH CT SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98501-9697
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-455-9068
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 BLACK HILLS LN SW
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98502-8661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-956-2562
Provider Business Practice Location Address Fax Number:
360-956-1894
Provider Enumeration Date:
05/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  PT00009619 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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