Healthcare Provider Details

I. General information

NPI: 1275916165
Provider Name (Legal Business Name): SEAN M WILDER APRN-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2015
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 W SWANN AVE FL 2
TAMPA FL
33606-2417
US

IV. Provider business mailing address

2995 DREW ST FL 2
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 813-254-7079
  • Fax: 813-443-8164
Mailing address:
  • Phone: 727-532-1355
  • Fax: 813-635-2613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number28224842A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN11001912
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: