Healthcare Provider Details

I. General information

NPI: 1619905767
Provider Name (Legal Business Name): J. NATHAN WILDER MS, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 01/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 YORK RD
TOWSON MD
21252-0001
US

IV. Provider business mailing address

2931 LOMOND PL
ABINGDON MD
21009-2675
US

V. Phone/Fax

Practice location:
  • Phone: 410-704-5224
  • Fax: 205-726-2099
Mailing address:
  • Phone: 410-967-8017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA0000281
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: