MEDICARE: MS. MARGARET ANN WILDER LMP

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	172V00000X	Community Health Worker	MA00004399	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0152509	OTHER	WA	LABOR AND INDUSTRIES

General Provider Information

NPI Number	:	1356683064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARGARET ANN WILDER LMP

Provider Business Mailing Address
First Line	:	390 ERICKSEN AVE NE
Second Line	:
City	:	BAINBRIDGE ISLAND
State	:	WA
Zip	:	98110-1854
Country	:	US
Telephone Number	:	206-883-7422
Fax Number	:

Provider Business Practice Location Address
First Line	:	390 ERICKSEN AVE NE
Second Line	:
City	:	BAINBRIDGE ISLAND
State	:	WA
Zip	:	98110-1854
Country	:	US
Telephone Number	:	206-883-7422
Fax Number	:

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

Provider Enumeration Date	:	03/20/2013
Last Update Date	:	03/20/2013

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