Basic Information
| Provider Information | |||||||||
| NPI: | 1861609521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILDER | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | JENNIFER | ||||||||
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| Credential: | MD MHS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034949000 | ||||||||
| FaxNumber: | 5034942391 | ||||||||
| Practice Location | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034949000 | ||||||||
| FaxNumber: | 5034942391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 12/30/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD25779 | OR | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 68171731 | 05 | CO | MEDICAID | 71557270 | 05 | NM | MEDICAID | 256334 | 05 | AZ | MEDICAID |