Provider Demographics
NPI:1265489801
Name:WILDE, ILAN E (PAC)
Entity Type:Individual
Prefix:MR
First Name:ILAN
Middle Name:E
Last Name:WILDE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-0190
Mailing Address - Country:US
Mailing Address - Phone:509-856-2395
Mailing Address - Fax:509-865-0757
Practice Address - Street 1:518 W 1ST AVE
Practice Address - Street 2:
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948-1564
Practice Address - Country:US
Practice Address - Phone:509-865-5600
Practice Address - Fax:509-865-5783
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004580363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant