=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285170696
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILSON POLITO PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2017
-----------------------------------------------------
Last Update Date | 06/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1844 W PULLMAN RD
-----------------------------------------------------
City | MOSCOW
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83843-4014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-883-1800
-----------------------------------------------------
Fax | 208-883-1811
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1844 W PULLMAN RD
-----------------------------------------------------
City | MOSCOW
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83843-4014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-883-1800
-----------------------------------------------------
Fax | 208-883-1811
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. NATHAN MICHAEL WILSON
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 208-743-5830
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ODP 100-222
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------