Healthcare Provider Details

I. General information

NPI: 1407223274
Provider Name (Legal Business Name): MICHAEL KENNETH WUCINICH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 9TH AVE N
TWIN FALLS ID
83301-6352
US

IV. Provider business mailing address

585 WASHINGTON ST N
TWIN FALLS ID
83301-3802
US

V. Phone/Fax

Practice location:
  • Phone: 208-537-7800
  • Fax:
Mailing address:
  • Phone: 208-210-4325
  • Fax: 208-415-4325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberPA-1274
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1274
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: