Provider Demographics
NPI:1366088502
Name:WILDMAN, BRYAN D (MA)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:D
Last Name:WILDMAN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:MR
Other - First Name:PRUDENCE
Other - Middle Name:C
Other - Last Name:WILDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:1755 SULLIVAN LN
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89431-2815
Mailing Address - Country:US
Mailing Address - Phone:775-499-5534
Mailing Address - Fax:775-544-4259
Practice Address - Street 1:1755 SULLIVAN LN
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-2815
Practice Address - Country:US
Practice Address - Phone:775-499-5534
Practice Address - Fax:775-544-4259
Is Sole Proprietor?:No
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1205389129Medicaid