Provider Demographics
NPI:1275916165
Name:WILDER, SEAN M (APRN-C)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:M
Last Name:WILDER
Suffix:
Gender:M
Credentials:APRN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2995 DREW ST FL 2
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-532-1355
Mailing Address - Fax:813-635-2613
Practice Address - Street 1:1919 W SWANN AVE FL 2
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2417
Practice Address - Country:US
Practice Address - Phone:813-254-7079
Practice Address - Fax:813-443-8164
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28224842A363LP0200X
FLAPRN11001912363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102642600Medicaid