Wildstate Lawton LLC

Primary specialty

Clinic/CenterTaxonomy code 261Q00000X

Legal business name

WILDSTATE LAWTON LLC

Practice address

2506 SW Lee Blvd
Lawton, OK 73505-8311

Phone

(580) 280-2558

NPI assigned

Oct 7, 2025

Last updated

Oct 20, 2025By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Mrs. Crystal Michelle Johnson, RN

Title

Owner

Phone

(580) 280-2558

Specialties & licenses 2

Addresses

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

  • Durable Medical Equipment & Medical Supplies
  • Lawton, OK
  • NPI 1043188261

  6002392297

  Same PAC ID

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Tax ID family

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

Other organizations with this tax ID 1

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

• Wildstate Lawton LLC

  • Durable Medical Equipment & Medical Supplies
  • Lawton, OK
  • NPI 1043188261
  NPD tax ID

Locations

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

• Wildstate Lawton LLC

  • Durable Medical Equipment & Medical Supplies
  • Lawton, OK
  • NPI 1043188261
  NPPES parent name

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Courtnie Lynn Alberry-Minnear, APRN, FNP-BC

  • Family Nurse Practitioner
  • Lawton, OK
  • NPI 1841996378
  Medicare reassignment NPD

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

{
    "created_epoch": "1759795200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1760918400000",
    "number": "1467327759",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2506 SW LEE BLVD",
            "city": "LAWTON",
            "state": "OK",
            "postal_code": "735058311",
            "telephone_number": "580-280-2558"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2506 SW LEE BLVD",
            "city": "LAWTON",
            "state": "OK",
            "postal_code": "735058311",
            "telephone_number": "580-280-2558"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2504 SW Lee Blvd",
            "address_purpose": "LOCATION",
            "city": "Lawton",
            "state": "OK",
            "postal_code": "735058311",
            "country_code": "US",
            "telephone_number": "580-250-1999",
            "fax_number": "580-353-9533",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "WILDSTATE LAWTON LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2025-10-07",
        "last_updated": "2025-10-20",
        "certification_date": "2025-10-20",
        "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_name_prefix": "Mrs.",
        "authorized_official_credential": "RN"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• 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
• William S, Davies, M.D., Inc.

• Clinic/Center in Lawton, OK
• Providers in Lawton, OK by specialty
• Clinic/Center in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 20, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.