Provider Demographics
NPI:1033262910
Name:WILDMAN, ROBERT JAY (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAY
Last Name:WILDMAN
Suffix:
Gender:M
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 1:2333 ALUMNI PARK PLZ
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4012
Mailing Address - Country:US
Mailing Address - Phone:859-257-7910
Mailing Address - Fax:
Practice Address - Street 1:2400 GREATSTONE PT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3274
Practice Address - Country:US
Practice Address - Phone:859-257-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA038363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95001236Medicaid
0621207Medicare ID - Type Unspecified
KY95001236Medicaid