Individual
MS. IVY MEG WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
2893 S CADET PL, BOISE, ID 83706-5133
(208) 313-8213
Mailing address
2893 S CADET PL, BOISE, ID 83706-5133
(208) 313-8213
Taxonomy
Speciality
Code
Description
License number
State
2471V0106X
Vascular-Interventional Technology Radiologic Technologist
541174
ID
363A00000X
Physician Assistant
Primary
—
ID
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
06/10/2022
Last updated
10/06/2022
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