Wildstate Lawton LLC

Primary specialty

Durable Medical Equipment & Medical SuppliesTaxonomy code 332B00000X

Legal business name

WILDSTATE LAWTON LLC

Practice address

2504 SW Lee Blvd
Lawton, OK 73505-8311

Phone

(580) 250-1999

NPI assigned

Oct 28, 2025

Organization subpart

Yes

Parent organization

WILDSTATE LAWTON LLCAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Crystal Michelle Johnson, RN

Title

Owner

Phone

(580) 280-2558

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in OK

Enrollment records 1

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

• Wildstate Lawton LLC

  • Clinic/Center
  • Lawton, OK
  • NPI 1467327759

  6002392297

  Same PAC ID

Tax ID family

Wildstate Lawton LLC2 organizations share this tax ID, including this one

Part of

Wildstate Lawton LLC

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Wildstate Lawton LLC

  • Clinic/Center
  • Lawton, OK
  • NPI 1467327759
  NPD tax ID

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

• Wildstate Lawton LLC

  • Clinic/Center
  • Lawton, OK
  • NPI 1467327759
  NPPES parent name

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1761609600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1788220800000",
    "number": "1043188261",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2504 SW LEE BLVD",
            "city": "LAWTON",
            "state": "OK",
            "postal_code": "735058311",
            "telephone_number": "580-250-1999"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2504 SW LEE BLVD",
            "city": "LAWTON",
            "state": "OK",
            "postal_code": "735058311",
            "telephone_number": "580-250-1999"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WILDSTATE LAWTON LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WILDSTATE LAWTON LLC",
        "enumeration_date": "2025-10-28",
        "last_updated": "2026-09-01",
        "certification_date": "2026-09-01",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "CRYSTAL",
        "authorized_official_middle_name": "MICHELLE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "580-280-2558",
        "authorized_official_credential": "RN"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "DBA WILDSTATE HOME MEDICAL",
            "identifier": "1043188261",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kori Wren Wiegmann, RN
• Bailey E Wiggins, DO
• Manuela Wikinger-Henry, MS,MHP,LMFT UNDER SU
• Nicole Lee Wilbanks
• Cali Wilcox
• Wildstate Lawton LLC
• Crystal Renee Wiley
• Emmett Wilkerson
• Donna Suzanne Willeford, PT
• William Cater Jr., DDS

• Durable Medical Equipment & Medical Supplies in Lawton, OK
• Providers in Lawton, OK by specialty
• Durable Medical Equipment & Medical Supplies in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 1, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.