Healthcare Provider Details

I. General information

NPI: 1982835385
Provider Name (Legal Business Name): VICTORIA CHLARSON WILDING MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2009
Last Update Date: 06/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS ROAD SOUTH TOWER, 6 WEST
BOISE ID
83706
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-4343
  • Fax: 208-367-7667
Mailing address:
  • Phone: 208-367-4343
  • Fax: 208-367-7667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberM-12470
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberM-12470
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: