Provider Demographics
NPI:1750734265
Name:WILD, SAMANTHA (APRN FNP-C)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:WILD
Suffix:
Gender:F
Credentials:APRN FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23218 BISON CYN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78261-2673
Mailing Address - Country:US
Mailing Address - Phone:210-310-9833
Mailing Address - Fax:
Practice Address - Street 1:5282 MEDICAL DRIVE # 206
Practice Address - Street 2:PARAGON SAN ANTONIO INFUSION CENTER
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-366-4358
Practice Address - Fax:210-366-4896
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP131123363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily