Provider Demographics
NPI:1255915369
Name:WILDE, HARLEY DANIELLE (PA)
Entity type:Individual
Prefix:
First Name:HARLEY
Middle Name:DANIELLE
Last Name:WILDE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6139
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78502-6139
Mailing Address - Country:US
Mailing Address - Phone:956-362-3636
Mailing Address - Fax:956-362-2699
Practice Address - Street 1:902 S AIRPORT DR. STE 6
Practice Address - Street 2:
Practice Address - City:WESLACO
Practice Address - State:TX
Practice Address - Zip Code:78596-6644
Practice Address - Country:US
Practice Address - Phone:956-362-8700
Practice Address - Fax:956-647-5013
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA14526363A00000X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine