Healthcare Provider Details

I. General information

NPI: 1124670799
Provider Name (Legal Business Name): SARAH WILDER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 OAKDALE AVE N
ROBBINSDALE MN
55422-2926
US

IV. Provider business mailing address

3300 OAKDALE AVE N
ROBBINSDALE MN
55422-2926
US

V. Phone/Fax

Practice location:
  • Phone: 763-581-3702
  • Fax: 763-581-3701
Mailing address:
  • Phone: 763-581-3702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number12997
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12997
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: