Provider Demographics
NPI:1619905767
Name:WILDER, J. NATHAN (MS, ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:J. NATHAN
Middle Name:
Last Name:WILDER
Suffix:
Gender:M
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2931 LOMOND PL
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:MD
Mailing Address - Zip Code:21009-2675
Mailing Address - Country:US
Mailing Address - Phone:410-967-8017
Mailing Address - Fax:
Practice Address - Street 1:8000 YORK RD
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21252-0001
Practice Address - Country:US
Practice Address - Phone:410-704-5224
Practice Address - Fax:205-726-2099
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00002812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer