Provider Demographics
NPI:1467563197
Name:WILDAUER, JEAN M (NP)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:M
Last Name:WILDAUER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 SUNRISE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-8010
Mailing Address - Country:US
Mailing Address - Phone:717-274-3912
Mailing Address - Fax:717-274-3912
Practice Address - Street 1:120 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19606-2871
Practice Address - Country:US
Practice Address - Phone:610-779-1330
Practice Address - Fax:610-779-5929
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP006245C363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner