MEDICARE: MR. SEAN M WILDER APRN-C

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	363LP0200X	Pediatric Nurse Practitioner	28224842A	IN
2	363LP2300X	Primary Care Nurse Practitioner	APRN11001912	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275916165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SEAN M WILDER APRN-C

Provider Business Mailing Address
First Line	:	2995 DREW ST FL 2
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33759-3012
Country	:	US
Telephone Number	:	727-532-1355
Fax Number	:	813-635-2613

Provider Business Practice Location Address
First Line	:	1919 W SWANN AVE FL 2
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33606-2417
Country	:	US
Telephone Number	:	813-254-7079
Fax Number	:	813-443-8164

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

Provider Enumeration Date	:	07/09/2015
Last Update Date	:	05/08/2019

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