MEDICARE: WILD SAGE PSYCHIATRY, LLC

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
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1730030602
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILD SAGE PSYCHIATRY, LLC

Provider Business Mailing Address
First Line	:	210 POLK ST STE 4B
Second Line	:
City	:	PORT TOWNSEND
State	:	WA
Zip	:	98368-6739
Country	:	US
Telephone Number	:	360-390-2701
Fax Number	:	360-443-5045

Provider Business Practice Location Address
First Line	:	210 POLK ST STE 4B
Second Line	:
City	:	PORT TOWNSEND
State	:	WA
Zip	:	98368-6739
Country	:	US
Telephone Number	:	360-390-2701
Fax Number	:	360-443-5045

Authorized Official
Title or Position	:	OWNER
Name	:	MONIQUEA JEAN DEGAN
Credential	:
Telephone Number	:	360-390-2701

Provider Enumeration Date	:	02/06/2026
Last Update Date	:	03/07/2026

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