Individual
JOHNATHON CHASE WILDE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
3820 CRESTWOOD LN, IDAHO FALLS, ID 83404-4979
(208) 552-7700
Mailing address
3820 CRESTWOOD LN, IDAHO FALLS, ID 83404-4979
(208) 552-7700
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
8361377
ID
Other
Enumeration date
08/16/2022
Last updated
09/26/2024
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