1396701520 NPI number — MR. JASON WILDEMAN OTR/L

Table of content: MR. JASON WILDEMAN OTR/L (NPI 1396701520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396701520 NPI number — MR. JASON WILDEMAN OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILDEMAN
Provider First Name:
JASON
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396701520
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3351 SW 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTONVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72712-9137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-936-6265
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3351 SW 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTONVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72712-9137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-936-6265
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OTR 1463 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5W780 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".