Healthcare Provider Details

I. General information

NPI: 1275748089
Provider Name (Legal Business Name): JARED KENT WILSON PA-C, MPAS, MED, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 08/03/2025
Certification Date: 08/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HOSPITAL WAY SOUTH MOB, SUITE 204
POCATELLO ID
83201-5175
US

IV. Provider business mailing address

777 HOSPITAL WAY SOUTH MOB, SUITE 204
POCATELLO ID
83201-5175
US

V. Phone/Fax

Practice location:
  • Phone: 208-239-2110
  • Fax: 208-239-2119
Mailing address:
  • Phone: 208-239-2110
  • Fax: 208-239-2119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-952
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-492
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: