Provider Demographics
NPI:1912575754
Name:WILDER, JUSTIN (PT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:WILDER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 SW PLAZA PKWY
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-7013
Mailing Address - Country:US
Mailing Address - Phone:515-964-2322
Mailing Address - Fax:515-224-5140
Practice Address - Street 1:1711 SW PLAZA PKWY
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-7013
Practice Address - Country:US
Practice Address - Phone:515-964-2322
Practice Address - Fax:515-224-5140
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA107534225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist