Provider Demographics
NPI:1184897670
Name:WILD, KATHLEEN JOANNE (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JOANNE
Last Name:WILD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:JOANNE WILD
Other - Last Name:CLICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1476
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24212-1476
Mailing Address - Country:US
Mailing Address - Phone:276-628-9794
Mailing Address - Fax:276-628-1260
Practice Address - Street 1:16000 JOHNSTON MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7659
Practice Address - Country:US
Practice Address - Phone:276-628-9794
Practice Address - Fax:276-628-1260
Is Sole Proprietor?:No
Enumeration Date:2008-04-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.29730207L00000X
VA0101251512207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology