MEDICARE: MR. JACK ANTHONY WILDER PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251X0800X	Orthopedic Physical Therapist	PT00009619	WA

General Provider Information

NPI Number	:	1326269739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACK ANTHONY WILDER PT

Provider Business Mailing Address
First Line	:	4701 77TH CT SE
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98501-9697
Country	:	US
Telephone Number	:	360-455-9068
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 BLACK HILLS LN SW
Second Line	:	SUITE G
City	:	OLYMPIA
State	:	WA
Zip	:	98502-8661
Country	:	US
Telephone Number	:	360-956-2562
Fax Number	:	360-956-1894

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	07/08/2007

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