Healthcare Provider Details

I. General information

NPI: 1811200140
Provider Name (Legal Business Name): DANIEL LEE WILDER PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 TAZEWELL PIKE
KNOXVILLE TN
37918-1874
US

IV. Provider business mailing address

6008 MORNING GLORY PL
KNOXVILLE TN
37912-4548
US

V. Phone/Fax

Practice location:
  • Phone: 865-686-1600
  • Fax: 865-686-3380
Mailing address:
  • Phone: 865-686-1600
  • Fax: 865-686-3380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7353
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: