Provider Demographics
NPI:1013698232
Name:WILDGUST, JOHN DAVID (RN, MSN, PHN)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DAVID
Last Name:WILDGUST
Suffix:
Gender:M
Credentials:RN, MSN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 HUNTER LN
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-8717
Mailing Address - Country:US
Mailing Address - Phone:707-480-2030
Mailing Address - Fax:707-588-9032
Practice Address - Street 1:935 HUNTER LN
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-8717
Practice Address - Country:US
Practice Address - Phone:707-480-2030
Practice Address - Fax:707-588-9032
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78261163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical