Provider Demographics
NPI:1134219470
Name:WILDT, ERIN A (PA)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:A
Last Name:WILDT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12416 66TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-3430
Mailing Address - Country:US
Mailing Address - Phone:275-474-7007
Mailing Address - Fax:727-394-8661
Practice Address - Street 1:1325 BELCHER RD STE A
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-6739
Practice Address - Country:US
Practice Address - Phone:727-547-4700
Practice Address - Fax:727-394-8661
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1142363A00000X
FL9107208363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00371588OtherMEDICARE RAILROAD
SC7111Medicare PIN
SCP00371588OtherMEDICARE RAILROAD