Provider Demographics
NPI:1942298609
Name:WILDER, JAMES MARCUS (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MARCUS
Last Name:WILDER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12938
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30703-7013
Mailing Address - Country:US
Mailing Address - Phone:706-602-7800
Mailing Address - Fax:
Practice Address - Street 1:160 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TRION
Practice Address - State:GA
Practice Address - Zip Code:30753-1125
Practice Address - Country:US
Practice Address - Phone:706-734-7302
Practice Address - Fax:706-734-7356
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6558363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2798978HMedicare PIN