Provider Demographics
NPI:1548409709
Name:DEWILDE, KATHRYN COLLEEN (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:COLLEEN
Last Name:DEWILDE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:COLLEEN
Other - Last Name:GOULD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:751 S BASCOM AVE
Mailing Address - Street 2:ANESTHESIOLOGY DEPT
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2604
Mailing Address - Country:US
Mailing Address - Phone:408-885-5000
Mailing Address - Fax:
Practice Address - Street 1:751 S BASCOM AVE
Practice Address - Street 2:ANESTHESIOLOGY DEPT
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2604
Practice Address - Country:US
Practice Address - Phone:408-885-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN652433367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered