Stephanie Abimbola Olawaiye Wilderness, PA-C

Primary specialty

Medical Physician AssistantTaxonomy code 363AM0700X

License

PA12712 Issued in TX

Practice address

6621 Fannin St
Houston, TX 77030-2399

Phone

(832) 826-1075

NPI assigned

Mar 30, 2019

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Interoperability endpoints

• FHIR API: https://api.platform.athenahealth.com/16372/brand/1/csg/1/fhir/r4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Texas Children'S Physician Group

  • Pediatrics Physician
  • Houston, TX
  • NPI 1861675506
  Medicare reassignment
• Womankind OB/GYN PA

  • Obstetrics & Gynecology Physician
  • McAllen, TX
  • NPI 1427258912
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1553904000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1662768000000",
    "number": "1871054833",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6621 FANNIN ST",
            "city": "HOUSTON",
            "state": "TX",
            "postal_code": "770302399",
            "telephone_number": "832-826-1075"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6621 FANNIN ST",
            "city": "HOUSTON",
            "state": "TX",
            "postal_code": "770302399",
            "telephone_number": "832-826-1075"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WILDERNESS",
        "first_name": "STEPHANIE",
        "middle_name": "ABIMBOLA OLAWAIYE",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-03-30",
        "last_updated": "2022-09-10",
        "certification_date": "2022-09-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "TX",
            "license": "PA12712",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Lynn Wilde, COTA
• Mark C. Wilde, PSY.D.
• Angelica Marie Wilder
• Joseph Wilder, MD
• Melissa Lynne Wilder, MPH, RD, LD
• Kimberly Ann Wildes, DRPH, MA, LPC-I
• Mae Wildredge-Maddock
• Charles Franklin Wiley, MS, LCDC
• Delois Jean Wiley, RPH
• Ginny Wiley

• Medical Physician Assistant in Houston, TX
• Providers in Houston, TX by specialty
• Medical Physician Assistant in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 10, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.