Individual
DAKOTA WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1950 E CLARK ST, POCATELLO, ID 83201-3314
(208) 232-7246
Mailing address
1950 E CLARK ST, POCATELLO, ID 83201-3314
(208) 232-7246
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA-2347
ID
390200000X
Student in an Organized Health Care Education/Training Program
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Other
Enumeration date
06/10/2022
Last updated
09/26/2022
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