Provider Demographics
NPI:1578668620
Name:WILDES, THOMAS W (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:W
Last Name:WILDES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 BRANDON PARK CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-3946
Mailing Address - Country:US
Mailing Address - Phone:813-655-9613
Mailing Address - Fax:
Practice Address - Street 1:110 SOUTHERN OAKS DR
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-1446
Practice Address - Country:US
Practice Address - Phone:813-752-0757
Practice Address - Fax:813-752-0753
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 3714363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS64460Medicare UPIN
FLE134ZMedicare ID - Type Unspecified