Provider Demographics
NPI:1902882558
Name:WILD, MATTHEW ALAN (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALAN
Last Name:WILD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:MATT
Other - Middle Name:A
Other - Last Name:HIRSCHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 TOWN PLZ # 67
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5104
Mailing Address - Country:US
Mailing Address - Phone:970-412-9808
Mailing Address - Fax:
Practice Address - Street 1:400 S CLARK ST
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-2328
Practice Address - Country:US
Practice Address - Phone:406-723-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA0370367500000X
COCRA-3451367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO41202Medicare PIN