MEDICARE: DAFNA RACHEL WILD PA

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	25MP00209700	NJ

General Provider Information

NPI Number	:	1174750319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAFNA RACHEL WILD PA

Provider Business Mailing Address
First Line	:	100 PAVONIA AVE
Second Line	:	SUITE 409
City	:	JERSEY CITY
State	:	NJ
Zip	:	07310-2778
Country	:	US
Telephone Number	:	201-626-4040
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 PAVONIA AVE
Second Line	:	SUITE 409
City	:	JERSEY CITY
State	:	NJ
Zip	:	07310-2778
Country	:	US
Telephone Number	:	201-626-4040
Fax Number	:

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

Provider Enumeration Date	:	06/15/2009
Last Update Date	:	06/15/2009

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Directions to “ DAFNA RACHEL WILD PA” Practice Location

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