Provider Demographics
NPI:1487900825
Name:WILD, CARLOS (CRNA)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:WILD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 YELLOWSTONE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-1915
Mailing Address - Country:US
Mailing Address - Phone:727-215-8177
Mailing Address - Fax:
Practice Address - Street 1:520 E EUCLID AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4414
Practice Address - Country:US
Practice Address - Phone:210-242-0020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX817053367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered