Provider Demographics
NPI:1780679704
Name:WILD, JOHN ANDREW (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANDREW
Last Name:WILD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SEWARD
Mailing Address - State:NE
Mailing Address - Zip Code:68434-2072
Mailing Address - Country:US
Mailing Address - Phone:402-643-6565
Mailing Address - Fax:402-643-4655
Practice Address - Street 1:905 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:NE
Practice Address - Zip Code:68434-2072
Practice Address - Country:US
Practice Address - Phone:402-643-6565
Practice Address - Fax:402-643-4655
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1017111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47082536500Medicaid
NE1780679704OtherNPI
NE272174OtherMEDICARE PTAN
NE470825365OtherTAX ID #
NE350046510OtherMEDICARE RR
NE350046510OtherMEDICARE RR