Provider Demographics
NPI:1013095157
Name:WILDT, KRISTY LYNNE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KRISTY
Middle Name:LYNNE
Last Name:WILDT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KRISTY
Other - Middle Name:LYNNE
Other - Last Name:BLUME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2306 CANYONLANDS DR APT F
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-4520
Mailing Address - Country:US
Mailing Address - Phone:314-652-4100
Mailing Address - Fax:
Practice Address - Street 1:915 N GRAND BLVD
Practice Address - Street 2:JOHN COCHRAN VETERANS ADMINISTRATION MEDICAL CENTER
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-1621
Practice Address - Country:US
Practice Address - Phone:314-652-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006001360363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant