Provider Demographics
NPI:1487938049
Name:WILDING, MATTHEW R (AA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:WILDING
Suffix:
Gender:M
Credentials:AA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6116 AVOCETRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LITHIA
Mailing Address - State:FL
Mailing Address - Zip Code:33547-4845
Mailing Address - Country:US
Mailing Address - Phone:201-240-8448
Mailing Address - Fax:
Practice Address - Street 1:6116 AVOCETRIDGE DR
Practice Address - Street 2:
Practice Address - City:LITHIA
Practice Address - State:FL
Practice Address - Zip Code:33547-4845
Practice Address - Country:US
Practice Address - Phone:201-240-8448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA107367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant