Provider Demographics
NPI:1518181916
Name:WILDER, CANDACE JOANN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:JOANN
Last Name:WILDER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 W DURHAM PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-3457
Mailing Address - Country:US
Mailing Address - Phone:918-455-5429
Mailing Address - Fax:918-687-4092
Practice Address - Street 1:3310 CHANDLER RD
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74403-4906
Practice Address - Country:US
Practice Address - Phone:918-686-0646
Practice Address - Fax:918-687-4092
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPTA532225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant