Provider Demographics
NPI:1861439770
Name:WILDMAN, KAREN M (MD)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:M
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 W 5TH AVE
Mailing Address - Street 2:SUITE 200W
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-4839
Mailing Address - Country:US
Mailing Address - Phone:509-624-2313
Mailing Address - Fax:
Practice Address - Street 1:104 W 5TH AVE
Practice Address - Street 2:SUITE 200W
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-4839
Practice Address - Country:US
Practice Address - Phone:509-624-2313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5169A207Q00000X
WAMD60026899207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1054554-00Medicaid
WAG8884292Medicare PIN
WY1054554-00Medicaid
WAG8881686Medicare PIN
WYW308473Medicare ID - Type Unspecified