Provider Demographics
NPI:1619137288
Name:WILDY, JONATHAN MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:WILDY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 W 73RD ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-2434
Mailing Address - Country:US
Mailing Address - Phone:619-600-1023
Mailing Address - Fax:
Practice Address - Street 1:5101 W 73RD ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE VILLAGE
Practice Address - State:KS
Practice Address - Zip Code:66208-2434
Practice Address - Country:US
Practice Address - Phone:619-600-1023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1390081012163W00000X
CA390200000X
CA3906367500000X
VA0024168911367500000X
KS556930367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program