Basic Information
| Provider Information | |||||||||
| NPI: | 1255915369 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILDE | ||||||||
| FirstName: | HARLEY | ||||||||
| MiddleName: | DANIELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6139 | ||||||||
| Address2: | |||||||||
| City: | MCALLEN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785026139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563623636 | ||||||||
| FaxNumber: | 9563622699 | ||||||||
| Practice Location | |||||||||
| Address1: | 5520 LEONARDO DA VINCI STE 100 | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785391422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563623636 | ||||||||
| FaxNumber: | 9563622699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2021 | ||||||||
| LastUpdateDate: | 02/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081S0010X | PA14526 | TX | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Sports Medicine | 363A00000X | PA14526 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.