Healthcare Provider Details

I. General information

NPI: 1225253305
Provider Name (Legal Business Name): WILDE FOOT & ANKLE CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 E CENTENNIAL DR
PITTSBURG KS
66762-6505
US

IV. Provider business mailing address

407 E CENTENNIAL DR
PITTSBURG KS
66762-6505
US

V. Phone/Fax

Practice location:
  • Phone: 620-231-5940
  • Fax: 620-231-5948
Mailing address:
  • Phone: 620-231-5940
  • Fax: 620-231-5948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1200315
License Number StateKS

VIII. Authorized Official

Name: DR. CORIN Q WILDE
Title or Position: OWNER
Credential: DPM
Phone: 620-231-5940