Healthcare Provider Details

I. General information

NPI: 1235660663
Provider Name (Legal Business Name): IDA MAYS WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IDA MAYLYNN MAYS

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 SURGICAL SERVICES WAY
KALISPELL MT
59901-4844
US

IV. Provider business mailing address

325 9TH AVE # 359796
SEATTLE WA
98104-2499
US

V. Phone/Fax

Practice location:
  • Phone: 406-751-5392
  • Fax: 406-751-5406
Mailing address:
  • Phone: 206-744-3564
  • Fax: 206-744-8582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD61288990
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMED-PHYS-LIC-126760
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberMED-PHYS-LIC-126760
License Number StateMT
# 5
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMED-PHYS-LIC-126760
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: