Provider Demographics
NPI:1669671228
Name:WILD, RONALD MICHAEL (PT)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:MICHAEL
Last Name:WILD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10684 E 35TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-6865
Mailing Address - Country:US
Mailing Address - Phone:928-580-5993
Mailing Address - Fax:
Practice Address - Street 1:10684 E 35TH ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85365-6865
Practice Address - Country:US
Practice Address - Phone:928-580-5993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist