Provider Demographics
NPI:1710501002
Name:WILBER, PATRICIA M (CST)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:M
Last Name:WILBER
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-446-5417
Mailing Address - Fax:765-446-5317
Practice Address - Street 1:3930 MEZZANINE DR STE D
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-8646
Practice Address - Country:US
Practice Address - Phone:765-807-2784
Practice Address - Fax:765-807-2786
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
107477246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist