Provider Demographics
NPI:1770174161
Name:WILDE, TROY (LAT)
Entity type:Individual
Prefix:
First Name:TROY
Middle Name:
Last Name:WILDE
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ASU STATION #10899
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76909-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:ASU STATION #10899
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76909-1767
Practice Address - Country:US
Practice Address - Phone:325-659-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT36322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer