Provider Demographics
NPI:1336152776
Name:WILD, NANCY K (NP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:K
Last Name:WILD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 FISH HATCHERY RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1911
Mailing Address - Country:US
Mailing Address - Phone:608-252-8000
Mailing Address - Fax:608-252-8233
Practice Address - Street 1:1313 FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1911
Practice Address - Country:US
Practice Address - Phone:608-252-8000
Practice Address - Fax:608-252-8233
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1724-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36010200Medicaid
WIP00327316Medicare PIN
WI36010200Medicaid
WI015A74150Medicare PIN
WIP00327316Medicare PIN