Provider Demographics
NPI:1952903957
Name:WILDER, ROBERT L
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:WILDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6911 TAYLOR RANCH RD NW STE C8
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-2962
Mailing Address - Country:US
Mailing Address - Phone:505-792-3311
Mailing Address - Fax:
Practice Address - Street 1:6911 TAYLOR RANCH RD NW STE C8
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-2962
Practice Address - Country:US
Practice Address - Phone:505-792-3311
Practice Address - Fax:505-792-3312
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMT9370225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist