Provider Demographics
NPI:1497837462
Name:WILDERMAN, LOIS ANN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:LOIS
Middle Name:ANN
Last Name:WILDERMAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:MRS
Other - First Name:LOIS
Other - Middle Name:WILDERMAN
Other - Last Name:BAIRD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3632 ROLLING MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-2625
Mailing Address - Country:US
Mailing Address - Phone:817-858-9745
Mailing Address - Fax:
Practice Address - Street 1:FAMILY GERIATRICS
Practice Address - Street 2:5348 DAVIS BLVD
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76180
Practice Address - Country:US
Practice Address - Phone:817-605-1707
Practice Address - Fax:817-605-1710
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX535611363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX03689OtherTX STATE BOARD OF NURSE E
P06687Medicare UPIN
85N003Medicare ID - Type Unspecified