Provider Demographics
NPI:1982604096
Name:WILD CREA, MARY THERESA (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:THERESA
Last Name:WILD CREA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1286 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1820
Mailing Address - Country:US
Mailing Address - Phone:651-455-9697
Mailing Address - Fax:651-455-2012
Practice Address - Street 1:5975 CARMEN AVE
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55076-4416
Practice Address - Country:US
Practice Address - Phone:651-455-9697
Practice Address - Fax:651-455-2012
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN38767174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist