Provider Demographics
NPI:1982899027
Name:WILDER, NAOMI NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:NICOLE
Last Name:WILDER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NAOMI
Other - Middle Name:NICOLE
Other - Last Name:SHENCAVITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1101 NOTT ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12308-2425
Mailing Address - Country:US
Mailing Address - Phone:518-243-4000
Mailing Address - Fax:
Practice Address - Street 1:1205 TROY SCHENECTADY RD STE 101
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1074
Practice Address - Country:US
Practice Address - Phone:518-348-3176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012007363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01529253Medicaid
55136AMedicare UPIN
NYJ400041763Medicare PIN