Provider Demographics
NPI:1245558527
Name:WILD, ELAINA CONSTANCE (ELAINA WILD)
Entity Type:Individual
Prefix:DR
First Name:ELAINA
Middle Name:CONSTANCE
Last Name:WILD
Suffix:
Gender:F
Credentials:ELAINA WILD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21ST MDG 559 VINCENT STREET PAFB
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80914-1540
Mailing Address - Country:US
Mailing Address - Phone:719-556-5898
Mailing Address - Fax:
Practice Address - Street 1:21ST MDG 559 VINCENT STREET PAFB
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80914-1540
Practice Address - Country:US
Practice Address - Phone:402-294-2056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE30995207Q00000X
IN01071051A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine