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General NPI Number Information
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NPI Number | 1104573112
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Entity Type | Individual
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Provider Name | CASSIE NICOLE WILSON AGCANP
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Gender | Female
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Dates
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Enumeration Date | 03/09/2022
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Last Update Date | 09/13/2024
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Provider Practice Location Address
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Address Line | 1075 N CURTIS RD STE 101
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City | BOISE
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State | ID
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Zip | 83706-1348
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Country | US
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Telephone | 208-302-2800
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Fax | 208-302-2825
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Provider Business Mailing Address
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Address Line | PO BOX 31001-2360
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City | PASADENA
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State | CA
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Zip | 91110-2360
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Country | US
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Telephone | 208-367-5170
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Fax | 208-367-5180
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 66379
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License Number State | ID
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