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NPI Code Detail

MEDICARE: MATTHEW ALAN WILD CRNA

MEDICARE: MATTHEW ALAN WILD CRNA
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
1367500000XCertified Registered Nurse AnesthetistCRNA0370AZ
2367500000XCertified Registered Nurse AnesthetistCRA-3451CO

General Provider Information

NPI Number : 1902882558
Entity Type Code : Individual
Provider Name (Legal Business Name) : MATTHEW ALAN WILD CRNA
Provider Business Mailing Address
First Line : 10 TOWN PLZ # 67
Second Line :
City : DURANGO
State : CO
Zip : 81301-5104
Country : US
Telephone Number : 970-412-9808
Fax Number :
Provider Business Practice Location Address
First Line : 400 S CLARK ST
Second Line :
City : BUTTE
State : MT
Zip : 59701-2328
Country : US
Telephone Number : 406-723-2500
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/15/2005
Last Update Date : 09/06/2019

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