Healthcare Provider Details

I. General information

NPI: 1487569109
Provider Name (Legal Business Name): DANA MARIE WILSON CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DANA MARIE GOERGEN

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8552 N GOVERNMENT WAY
HAYDEN ID
83835-9280
US

IV. Provider business mailing address

712 N MONROE AVE
SANDPOINT ID
83864-2114
US

V. Phone/Fax

Practice location:
  • Phone: 208-772-2600
  • Fax:
Mailing address:
  • Phone: 208-627-7437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: