| Doctor Name: | JEREMY LEE WILT |
| NPI Number: | 1043689672 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | NP |
| License Number: | 28165750A |
| Business Practice Address: | 9431 County Road 403 Charlestown, IN - 471118946 |
| Business Phone Number: | 8122566391 |
| Business Fax Number: | |
| Mailing Address: | 9431 County Road 403, CHARLESTOWN |
| State: | IN |
| Postal Code: | 471118946 |
| Phone Number: | 8122566391 |
| Fax Number: | |
| NPI Enumeration Date: | 09/24/2015 |
| NPI Last Update Date: | 09/24/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | 28165750A |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IN |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |