MEDICARE: JEREMY LEE WILT NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	71005761A	IN
2	363LF0000X	Family Nurse Practitioner	28165750A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	F0915751	OTHER	IN	AANP CERTIFICATION
2	28165750A	OTHER	IN	INDIANA LICENSE NUMBER

General Provider Information

NPI Number	:	1043689672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY LEE WILT NP

Provider Business Mailing Address
First Line	:	9431 COUNTY ROAD 403
Second Line	:
City	:	CHARLESTOWN
State	:	IN
Zip	:	47111-8946
Country	:	US
Telephone Number	:	812-256-6391
Fax Number	:

Provider Business Practice Location Address
First Line	:	9431 COUNTY ROAD 403
Second Line	:
City	:	CHARLESTOWN
State	:	IN
Zip	:	47111-8946
Country	:	US
Telephone Number	:	812-256-6391
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2015
Last Update Date	:	11/06/2023

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