Provider Demographics
NPI:1558361535
Name:WILDE, PAUL MICHAEL (PA-C, SCD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:MICHAEL
Last Name:WILDE
Suffix:
Gender:M
Credentials:PA-C, SCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5034 MUND RD
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66218-9147
Mailing Address - Country:US
Mailing Address - Phone:913-422-8477
Mailing Address - Fax:913-322-4562
Practice Address - Street 1:550 POPE AVE
Practice Address - Street 2:
Practice Address - City:FORT LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-2332
Practice Address - Country:US
Practice Address - Phone:913-684-6198
Practice Address - Fax:913-684-6128
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1002775 NCCPA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical