Basic Information
| Provider Information | |||||||||
| NPI: | 1275916165 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILDER | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APRN-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2995 DREW ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337593012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275321355 | ||||||||
| FaxNumber: | 8136352613 | ||||||||
| Practice Location | |||||||||
| Address1: | 1919 W SWANN AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336062417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132547079 | ||||||||
| FaxNumber: | 8134438164 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2015 | ||||||||
| LastUpdateDate: | 05/08/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 28224842A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP2300X | APRN11001912 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 102642600 | 05 | FL | MEDICAID |