MEDICARE: KATHLEEN WHITE WILSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	266	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	95503	OTHER	MT	BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578518692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN WHITE WILSON PA-C

Provider Business Mailing Address
First Line	:	350 HERITAGE WAY
Second Line	:	SUITE 1300
City	:	KALISPELL
State	:	MT
Zip	:	59901-3158
Country	:	US
Telephone Number	:	406-752-5170
Fax Number	:	406-752-5120

Provider Business Practice Location Address
First Line	:	75 CLAREMONT ST STE A
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-3500
Country	:	US
Telephone Number	:	406-752-8282
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2006
Last Update Date	:	11/27/2023

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