Healthcare Provider Details

I. General information

NPI: 1831461680
Provider Name (Legal Business Name): PHYLICIA MARY WILDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 02/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TOKSOOK BAY SUB REGIONAL CLINIC
TOKSOOK BAY AK
99637-0028
US

IV. Provider business mailing address

PO BOX 37028
TOKSOOK BAY AK
99637-0028
US

V. Phone/Fax

Practice location:
  • Phone: 907-427-3500
  • Fax: 907-427-3526
Mailing address:
  • Phone: 907-427-3500
  • Fax: 907-427-3526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: