Provider Demographics
NPI:1134674518
Name:WILDER, PAMELA ROSE (NP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:ROSE
Last Name:WILDER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SHADY GROVE LN
Mailing Address - Street 2:
Mailing Address - City:MIDLAND CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36350-7102
Mailing Address - Country:US
Mailing Address - Phone:850-774-4826
Mailing Address - Fax:
Practice Address - Street 1:4370 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1056
Practice Address - Country:US
Practice Address - Phone:334-793-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-16
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE62370163W00000X
AL1-157417363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse