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General NPI Number Information
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NPI Number | 1013698232
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Entity Type | Individual
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Provider Name | JOHN DAVID WILDGUST RN, MSN, PHN, PMHNP
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Gender | Male
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Dates
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Enumeration Date | 07/31/2023
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Last Update Date | 04/09/2025
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Provider Practice Location Address
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Address Line | 480 TESCONI CIR STE B
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City | SANTA ROSA
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State | CA
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Zip | 95401-4691
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Country | US
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Telephone | 707-206-7268
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Fax | 707-206-7254
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Provider Business Mailing Address
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Address Line | 935 HUNTER LN
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City | SANTA ROSA
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State | CA
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Zip | 95404-8717
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Country | US
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Telephone | 707-480-2030
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Fax | 707-588-9032
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WM0705X
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Taxonomy Name | Medical-Surgical Registered Nurse
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License Number | 78261
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | NP95034156
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License Number State | CA
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