Provider Demographics
NPI:1639855075
Name:WILD, ABIGAIL CLAIRE (DPT)
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:CLAIRE
Last Name:WILD
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2635 4TH ST SE APT 1110
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3869
Mailing Address - Country:US
Mailing Address - Phone:434-249-8823
Mailing Address - Fax:
Practice Address - Street 1:23415 THREE NOTCH RD STE 2026
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:MD
Practice Address - Zip Code:20619-4021
Practice Address - Country:US
Practice Address - Phone:240-530-8188
Practice Address - Fax:240-237-8572
Is Sole Proprietor?:No
Enumeration Date:2023-06-22
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13171225100000X
MD30282225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist