Provider Demographics
NPI:1770263469
Name:WILDE, NIKOLAS SANDQUIST (PA-C)
Entity type:Individual
Prefix:
First Name:NIKOLAS
Middle Name:SANDQUIST
Last Name:WILDE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 US HIGHWAY 1 BYP UNIT 102
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7105
Mailing Address - Country:US
Mailing Address - Phone:603-410-6700
Mailing Address - Fax:603-319-8308
Practice Address - Street 1:800 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1552
Practice Address - Country:US
Practice Address - Phone:505-500-5093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-19
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1209260363A00000X
MAPA9559363A00000X
IL085010340363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant