Basic Information
| Provider Information | |||||||||
| NPI: | 1144623638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILDBILL | ||||||||
| FirstName: | TANIA | ||||||||
| MiddleName: | CAROLA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 73265 CONFEDERATED WAY | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978019099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419669830 | ||||||||
| FaxNumber: | 5412787572 | ||||||||
| Practice Location | |||||||||
| Address1: | 73265 CONFEDERATED WAY | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978019099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419669830 | ||||||||
| FaxNumber: | 5412787572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2014 | ||||||||
| LastUpdateDate: | 09/29/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174H00000X | Y | Other Service Providers | Health Educator |
ID Information
| ID | Type | State | Issuer | Description | 171037 | 05 | OR | MEDICAID |