Provider Demographics
NPI:1902888548
Name:WILDMAN, LESLINE WALLACE (CRNA)
Entity Type:Individual
Prefix:
First Name:LESLINE
Middle Name:WALLACE
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 E FLETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-4613
Mailing Address - Country:US
Mailing Address - Phone:813-615-7914
Mailing Address - Fax:813-615-8134
Practice Address - Street 1:3100 E FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4613
Practice Address - Country:US
Practice Address - Phone:813-615-7914
Practice Address - Fax:813-615-8134
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP918952367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL034811200Medicaid
430028310OtherRAILROAD MEDICARE
FLG0431OtherBCBS
FL$$$$$$$$$OtherTRICARE
FLG0431WMedicare ID - Type Unspecified