Individual
CODY ELIJAH WISSENBACH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.A.
Contact information
Practice address
999 N CURTIS RD STE 415, BOISE, ID 83706-1334
(208) 302-2600
(208) 302-2625
Mailing address
PO BOX 190930, BOISE, ID 83719-0930
(208) 367-5170
(208) 367-5180
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA-2289
ID
363A00000X
Physician Assistant
PA1091
NV
363A00000X
Physician Assistant
PA60720417
WA
Other
Enumeration date
02/15/2008
Last updated
11/14/2023
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