=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174513188
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THAD W WILKEY PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2005
-----------------------------------------------------
Last Update Date | 01/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2101 N WHITLEY DR
-----------------------------------------------------
City | FRUITLAND
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83619-2132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-452-5999
-----------------------------------------------------
Fax | 208-452-4499
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2101 N WHITLEY DR
-----------------------------------------------------
City | FRUITLAND
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83619-2132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-452-5999
-----------------------------------------------------
Fax | 208-452-4499
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA280
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------