Individual
RAEGAN DEWILDE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
523 E STATE RD, FAIRVIEW, OK 73737-1453
(580) 227-2585
Mailing address
716 S HICKORY ST, SAPULPA, OK 74066-5130
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
—
—
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
10/08/2019
Last updated
06/08/2022
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