Healthcare Provider Details

I. General information

NPI: 1013698232
Provider Name (Legal Business Name): JOHN DAVID WILDGUST RN, MSN, PHN, PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 TESCONI CIR STE B
SANTA ROSA CA
95401-4691
US

IV. Provider business mailing address

935 HUNTER LN
SANTA ROSA CA
95404-8717
US

V. Phone/Fax

Practice location:
  • Phone: 707-206-7268
  • Fax: 707-206-7254
Mailing address:
  • Phone: 707-480-2030
  • Fax: 707-588-9032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number78261
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP95034156
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: