Healthcare Provider Details

I. General information

NPI: 1417879404
Provider Name (Legal Business Name): ISAIAH WILSON PLADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 1ST AVE
SCOTTSBLUFF NE
69361-3106
US

IV. Provider business mailing address

1509 1ST AVE
SCOTTSBLUFF NE
69361-3106
US

V. Phone/Fax

Practice location:
  • Phone: 308-635-1488
  • Fax:
Mailing address:
  • Phone: 308-635-1488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberP-2439
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: