Provider Demographics
NPI:1588810519
Name:WILD, CHRISTY (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:
Last Name:WILD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHRISTY
Other - Middle Name:
Other - Last Name:BOONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5818 HARBOUR VIEW BLVD STE 240
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-3315
Mailing Address - Country:US
Mailing Address - Phone:757-397-2383
Mailing Address - Fax:757-397-5301
Practice Address - Street 1:5818 HARBOUR VIEW BLVD STE 240
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3315
Practice Address - Country:US
Practice Address - Phone:757-397-2383
Practice Address - Fax:757-397-5301
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002797363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant