MEDICARE: MS. LASHANA JONETTE WILDER P.A.

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	363A00000X	Physician Assistant	1253	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1253	OTHER	SC	SC MEDICAL LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396927125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LASHANA JONETTE WILDER P.A.

Provider Business Mailing Address
First Line	:	PO BOX 632516
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45263-2516
Country	:	US
Telephone Number	:	888-472-0043
Fax Number	:	513-653-4122

Provider Business Practice Location Address
First Line	:	1064 GARDNER RD STE 208
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29407-1712
Country	:	US
Telephone Number	:	843-824-4786
Fax Number	:

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

Provider Enumeration Date	:	12/04/2007
Last Update Date	:	05/26/2026

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