Provider Demographics
NPI:1174981336
Name:ROMAN, WILDALYS
Entity type:Individual
Prefix:
First Name:WILDALYS
Middle Name:
Last Name:ROMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 AVENIDA DR. SUSONI
Mailing Address - Street 2:
Mailing Address - City:HATILLO
Mailing Address - State:PR
Mailing Address - Zip Code:00659
Mailing Address - Country:US
Mailing Address - Phone:787-898-4190
Mailing Address - Fax:
Practice Address - Street 1:16 AVENIDA DR, SUSONI
Practice Address - Street 2:
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659
Practice Address - Country:US
Practice Address - Phone:787-898-4190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8695247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other