Provider Demographics
NPI:1477585446
Name:WILDER, TERESA GARVIN (NP-C)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:GARVIN
Last Name:WILDER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:ROBIN
Other - Last Name:GARVIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:777 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2102
Mailing Address - Country:US
Mailing Address - Phone:478-765-4132
Mailing Address - Fax:478-765-4171
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:478-765-4132
Practice Address - Fax:478-765-4171
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN060359363LN0005X, 363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA904870559AMedicaid