Basic Information
| Provider Information | |||||||||
| NPI: | 1356639918 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILDER | ||||||||
| FirstName: | LILLIAN | ||||||||
| MiddleName: | MARGARET | ||||||||
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| Credential: | CNIM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 AVENUE B | ||||||||
| Address2: | |||||||||
| City: | WINNIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776652359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135605386 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2150 TOWN SQUARE PLACE | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774791643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817686730 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2011 | ||||||||
| LastUpdateDate: | 09/23/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0600X | 1648 | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic |
No ID Information.