MEDICARE: GAIL SUE WILD CNP

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	363LF0000X	Family Nurse Practitioner	0204	SD
2	363LF0000X	Family Nurse Practitioner	R018558	SD

General Provider Information

NPI Number	:	1629016480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAIL SUE WILD CNP

Provider Business Mailing Address
First Line	:	353 FAIRMONT BLVD
Second Line	:	ATTEN MEDICAL STAFF SERVICES
City	:	RAPID CITY
State	:	SD
Zip	:	57701-6000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 13TH AVE
Second Line	:
City	:	BELLE FOURCHE
State	:	SD
Zip	:	57717
Country	:	US
Telephone Number	:	605-892-2701
Fax Number	:	605-644-4197

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

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	01/24/2013

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