Provider Demographics
NPI:1437177631
Name:WILDER, STEPHANIE RACHEL (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:RACHEL
Last Name:WILDER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:STEPHANIE
Other - Middle Name:RACHEL
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1720 E REEFOOT AVENUE
Mailing Address - Street 2:SUITE 104A
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261
Mailing Address - Country:US
Mailing Address - Phone:731-885-8484
Mailing Address - Fax:731-884-1609
Practice Address - Street 1:1720 E REELFOOT AVE
Practice Address - Street 2:STE 104 A
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261
Practice Address - Country:US
Practice Address - Phone:731-885-8484
Practice Address - Fax:731-884-1609
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1394363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3664494Medicaid
TN3664494Medicaid
TN3664494Medicare PIN