Provider Demographics
NPI:1609152776
Name:WILDE FORTNER, MISTY KAY (PA-C)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:KAY
Last Name:WILDE FORTNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 BRIARWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79707-2753
Mailing Address - Country:US
Mailing Address - Phone:432-682-5385
Mailing Address - Fax:432-682-1265
Practice Address - Street 1:5424 19TH ST STE 300
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407-2164
Practice Address - Country:US
Practice Address - Phone:806-795-4391
Practice Address - Fax:806-796-1354
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07530363A00000X
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant