Provider Demographics
NPI:1225783897
Name:WILDER, BRIANNA CAROLYN (PA-C)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:CAROLYN
Last Name:WILDER
Suffix:
Gender:
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 1:830 PRAIRIE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7301
Mailing Address - Country:US
Mailing Address - Phone:952-826-6500
Mailing Address - Fax:
Practice Address - Street 1:830 PRAIRIE CENTER DR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-7301
Practice Address - Country:US
Practice Address - Phone:952-826-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-12
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN14546363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program