Provider Demographics
NPI:1881845980
Name:WILD, CASEY MARIE (NP)
Entity Type:Individual
Prefix:MRS
First Name:CASEY
Middle Name:MARIE
Last Name:WILD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MAIN ST FL 5
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1009
Mailing Address - Country:US
Mailing Address - Phone:716-323-0170
Mailing Address - Fax:716-323-0297
Practice Address - Street 1:1001 MAIN ST FL 4
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1009
Practice Address - Country:US
Practice Address - Phone:716-323-0170
Practice Address - Fax:716-323-0297
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY381988363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03057545Medicaid