Healthcare Provider Details

I. General information

NPI: 1124219084
Provider Name (Legal Business Name): JAMES WILSON WEAR DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 12TH AVE RD
NAMPA ID
83686
US

IV. Provider business mailing address

124 12TH AVE RD
NAMPA ID
83686-5074
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-5459
  • Fax: 208-466-5803
Mailing address:
  • Phone: 208-466-5459
  • Fax: 208-466-5803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIA276
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberACC106
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: