Provider Demographics
NPI:1609154517
Name:WILDER, TRISHA J (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TRISHA
Middle Name:J
Last Name:WILDER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1236 NW BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-3125
Mailing Address - Country:US
Mailing Address - Phone:530-526-3218
Mailing Address - Fax:
Practice Address - Street 1:61250 SE COOMBS PL
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3704
Practice Address - Country:US
Practice Address - Phone:541-706-5930
Practice Address - Fax:541-706-5931
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21676363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical