Provider Demographics
NPI:1942391016
Name:WILDMAN, LAURA E (PAC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:E
Other - Last Name:BURCHETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:701 E MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-4412
Mailing Address - Country:US
Mailing Address - Phone:610-738-8016
Mailing Address - Fax:610-918-6316
Practice Address - Street 1:701 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4412
Practice Address - Country:US
Practice Address - Phone:610-738-8016
Practice Address - Fax:610-918-6316
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA050709363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical