Provider Demographics
NPI:1275965311
Name:WILDMAN, JOHN (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WILDMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:300 E BOYD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-2816
Mailing Address - Country:US
Mailing Address - Phone:317-462-5252
Mailing Address - Fax:317-462-8010
Practice Address - Street 1:300 E BOYD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-2816
Practice Address - Country:US
Practice Address - Phone:317-462-5252
Practice Address - Fax:317-462-8010
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2021-03-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN10001556A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN151560056Medicare PIN