Provider Demographics
NPI:1639855075
Name:WILD, ABIGAIL (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:ABIGAIL
Middle Name:
Last Name:WILD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2635 4TH ST SE APT 1110
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3869
Mailing Address - Country:US
Mailing Address - Phone:434-249-8823
Mailing Address - Fax:
Practice Address - Street 1:14101 FAIRVIEW DR STE 300
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-2537
Practice Address - Country:US
Practice Address - Phone:855-324-7843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13171225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist