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General NPI Number Information
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NPI Number | 1275748089
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Entity Type | Individual
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Provider Name | JARED KENT WILSON PA-C, MPAS, MED, ATC
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Gender | Male
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Dates
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Enumeration Date | 05/14/2007
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Last Update Date | 08/03/2025
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Provider Practice Location Address
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Address Line | 777 HOSPITAL WAY SOUTH MOB, SUITE 204
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City | POCATELLO
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State | ID
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Zip | 83201-5175
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Country | US
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Telephone | 208-239-2110
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Fax | 208-239-2119
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Provider Business Mailing Address
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Address Line | 777 HOSPITAL WAY SOUTH MOB, SUITE 204
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City | POCATELLO
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State | ID
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Zip | 83201-5175
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Country | US
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Telephone | 208-239-2110
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Fax | 208-239-2119
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT-492
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA-952
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License Number State | ID
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