Provider Demographics
NPI:1316385834
Name:WILDMAN, SARAH J (PA)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:J
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:J
Other - Last Name:CRICHLOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7120 CLEARVISTA DRIVE
Practice Address - Street 2:SUITE 2100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-0020
Practice Address - Country:US
Practice Address - Phone:317-621-5676
Practice Address - Fax:317-353-9338
Is Sole Proprietor?:No
Enumeration Date:2013-06-06
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN10001549A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01214579OtherRR MEDICARE PTAN
IN000000825360OtherANTHEM
INP01214579OtherRR MEDICARE PTAN