Provider Demographics
NPI:1861010837
Name:WILDER, QUINTON WIGGINS (LMT)
Entity Type:Individual
Prefix:MR
First Name:QUINTON
Middle Name:WIGGINS
Last Name:WILDER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-4349
Mailing Address - Country:US
Mailing Address - Phone:928-499-7041
Mailing Address - Fax:
Practice Address - Street 1:1590 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1164
Practice Address - Country:US
Practice Address - Phone:928-227-1899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-24842225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist