Healthcare Provider Details

I. General information

NPI: 1083302855
Provider Name (Legal Business Name): ALEXIS JANE WILDMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2023
Last Update Date: 06/28/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 SOUTHCREST PKWY
SOUTHAVEN MS
38671-4742
US

IV. Provider business mailing address

7601 SOUTHCREST PKWY
SOUTHAVEN MS
38671-4742
US

V. Phone/Fax

Practice location:
  • Phone: 662-772-4000
  • Fax:
Mailing address:
  • Phone: 662-772-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number37048
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number77086
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: