Healthcare Provider Details

I. General information

NPI: 1891450151
Provider Name (Legal Business Name): BAYLEE E WILDMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N WABASH AVE STE 360
MARION IN
46952-2678
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 765-664-3292
  • Fax: 765-662-7560
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10003381A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: