Provider Demographics
NPI:1407877038
Name:WILDEMAN, CHRISTINE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:LYNN
Last Name:WILDEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6350 MOUNTAIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-5963
Mailing Address - Country:US
Mailing Address - Phone:720-308-4228
Mailing Address - Fax:
Practice Address - Street 1:6350 MOUNTAIN VIEW DR
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134
Practice Address - Country:US
Practice Address - Phone:720-308-4228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45889207Q00000X
GA057705207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49553054Medicaid
G56225Medicare UPIN
COC811299Medicare PIN