Healthcare Provider Details

I. General information

NPI: 1174513188
Provider Name (Legal Business Name): THAD W WILKEY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 N WHITLEY DR
FRUITLAND ID
83619-2132
US

IV. Provider business mailing address

2101 N WHITLEY DR
FRUITLAND ID
83619-2132
US

V. Phone/Fax

Practice location:
  • Phone: 208-452-5999
  • Fax: 208-452-4499
Mailing address:
  • Phone: 208-452-5999
  • Fax: 208-452-4499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA280
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: