Provider Demographics
NPI:1043728868
Name:WILDER, MIKISA (NCMA)
Entity Type:Individual
Prefix:MS
First Name:MIKISA
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:NCMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5502 CEDAR AVE APT 1A
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-1930
Mailing Address - Country:US
Mailing Address - Phone:267-973-2312
Mailing Address - Fax:
Practice Address - Street 1:5502 CEDAR AVE APT 1A
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1930
Practice Address - Country:US
Practice Address - Phone:267-973-2312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-15
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA503146171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist