MEDICARE: JESSICA WILDE F.N.P

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP132311	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548711153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA WILDE F.N.P

Provider Business Mailing Address
First Line	:	4360 THOUSAND OAKS DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-2153
Country	:	US
Telephone Number	:	210-655-2300
Fax Number	:

Provider Business Practice Location Address
First Line	:	4360 THOUSAND OAKS DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78217-2153
Country	:	US
Telephone Number	:	210-655-2300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2016
Last Update Date	:	10/18/2016

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