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NPI Code Detail

MEDICARE: MICHAEL JOHN WILD MS, ATC, PES

MEDICARE: MICHAEL JOHN WILD MS, ATC, PES
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
12255A2300XAthletic Trainer7952261NY

General Provider Information

NPI Number : 1710390562
Entity Type Code : Individual
Provider Name (Legal Business Name) : MICHAEL JOHN WILD MS, ATC, PES
Provider Business Mailing Address
First Line : 5963 ROUTE 98
Second Line : PO BOX 7
City : GREAT VALLEY
State : NY
Zip : 14741-0007
Country : US
Telephone Number : 716-969-7581
Fax Number : 716-566-7858
Provider Business Practice Location Address
First Line : 4380 MAIN ST
Second Line :
City : AMHERST
State : NY
Zip : 14226-3544
Country : US
Telephone Number : 716-839-8581
Fax Number : 716-566-7858
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/10/2014
Last Update Date : 06/10/2014

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