Provider Demographics
NPI:1013698232
Name:WILDGUST, JOHN DAVID (RN, MSN, PHN, PMHNP)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DAVID
Last Name:WILDGUST
Suffix:
Gender:
Credentials:RN, MSN, PHN, PMHNP
Other - Prefix:
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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 1:480 TESCONI CIR STE B
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4691
Practice Address - Country:US
Practice Address - Phone:707-206-7268
Practice Address - Fax:707-206-7254
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA78261163WM0705X
CANP95034156363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical