Basic Information
Provider Information | |||||||||
NPI: | 1982899027 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILDER | ||||||||
FirstName: | NAOMI | ||||||||
MiddleName: | NICOLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SHENCAVITZ | ||||||||
OtherFirstName: | NAOMI | ||||||||
OtherMiddleName: | NICOLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1101 NOTT ST | ||||||||
Address2: |   | ||||||||
City: | SCHENECTADY | ||||||||
State: | NY | ||||||||
PostalCode: | 123082425 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5182434000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1205 TROY SCHENECTADY RD STE 101 | ||||||||
Address2: |   | ||||||||
City: | LATHAM | ||||||||
State: | NY | ||||||||
PostalCode: | 121101074 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5183483176 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2007 | ||||||||
LastUpdateDate: | 10/24/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 012007 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 01529253 | 05 | NY |   | MEDICAID |