Provider Demographics
NPI:1104576701
Name:WILDER-WIXSON, KATELIN ROSE (MD)
Entity type:Individual
Prefix:DR
First Name:KATELIN
Middle Name:ROSE
Last Name:WILDER-WIXSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9062 BAKER DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-2374
Mailing Address - Country:US
Mailing Address - Phone:337-329-5959
Mailing Address - Fax:
Practice Address - Street 1:5246 BRITTANY DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-9136
Practice Address - Country:US
Practice Address - Phone:337-329-5959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA345986207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2588397Medicaid