Basic Information
| Provider Information | |||||||||
| NPI: | 1184897670 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILD | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | JOANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLICK | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | JOANNE WILD | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1476 | ||||||||
| Address2: | |||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242121476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766289794 | ||||||||
| FaxNumber: | 2766281260 | ||||||||
| Practice Location | |||||||||
| Address1: | 16000 JOHNSTON MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242117659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766289794 | ||||||||
| FaxNumber: | 2766281260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2008 | ||||||||
| LastUpdateDate: | 02/07/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD.29730 | AL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 0101251512 | VA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.