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General NPI Number Information
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NPI Number | 1619137288
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Entity Type | Individual
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Provider Name | JONATHAN MICHAEL WILDY CRNA
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Gender | Male
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Dates
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Enumeration Date | 06/16/2008
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Last Update Date | 10/18/2011
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Provider Practice Location Address
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Address Line | 5101 W 73RD ST
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City | PRAIRIE VILLAGE
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State | KS
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Zip | 66208-2434
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Country | US
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Telephone | 619-600-1023
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Fax |
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Provider Business Mailing Address
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Address Line | 5101 W 73RD ST
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City | PRAIRIE VILLAGE
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State | KS
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Zip | 66208-2434
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Country | US
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Telephone | 619-600-1023
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Fax |
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 1390081012
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 3906
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 0024168911
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License Number State | VA
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Taxonomy #5
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 556930
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License Number State | KS
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