Provider Demographics
NPI:1255380580
Name:WILDER, JOYCE M (CNM, NP)
Entity type:Individual
Prefix:
First Name:JOYCE
Middle Name:M
Last Name:WILDER
Suffix:
Gender:F
Credentials:CNM, 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 W FAYETTE ST
Mailing Address - Street 2:STE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-472-1488
Mailing Address - Fax:315-476-1792
Practice Address - Street 1:172 CLINTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3602
Practice Address - Country:US
Practice Address - Phone:315-782-6262
Practice Address - Fax:315-782-5181
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY420516363LW0102X
NYF000546367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNPP000Medicare UPIN
NYRB0376Medicare PIN