Healthcare Provider Details

I. General information

NPI: 1831803584
Provider Name (Legal Business Name): PATRICK JOSEPH WILTSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 14TH ST SW
LARGO FL
33770-3133
US

IV. Provider business mailing address

35615 LONE PINE LN
FARMINGTON HILLS MI
48335-5802
US

V. Phone/Fax

Practice location:
  • Phone: 727-588-5200
  • Fax:
Mailing address:
  • Phone: 248-924-0984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704313517
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11034719
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: