Provider Demographics
NPI:1841942844
Name:WILDMAN, KHIARA (CRM)
Entity type:Individual
Prefix:
First Name:KHIARA
Middle Name:
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 E 14TH AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4379
Mailing Address - Country:US
Mailing Address - Phone:541-650-4672
Mailing Address - Fax:
Practice Address - Street 1:350 E 11TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3246
Practice Address - Country:US
Practice Address - Phone:541-257-7313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORAM56847EMedicaid