Provider Demographics
NPI:1144877341
Name:WILDER, MONICA ASHLEY
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:ASHLEY
Last Name:WILDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W MEMORIAL RD STE 112
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-2000
Mailing Address - Country:US
Mailing Address - Phone:405-509-6599
Mailing Address - Fax:
Practice Address - Street 1:2101 N VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-2524
Practice Address - Country:US
Practice Address - Phone:580-297-9993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK117508207Q00000X, 363LF0000X
KS53-79398-032363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine