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General NPI Number Information
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NPI Number | 1336734789
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Entity Type | Individual
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Provider Name | AUDRA LYNN WILSON PAC
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Gender | Female
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Dates
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Enumeration Date | 03/08/2021
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Last Update Date | 12/10/2024
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Provider Practice Location Address
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Address Line | 6140 W CURTISIAN AVE STE 400
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City | BOISE
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State | ID
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Zip | 83704-8907
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Country | US
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Telephone | 208-327-5600
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Fax | 208-327-5602
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Provider Business Mailing Address
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Address Line | 6140 W CURTISIAN AVE STE 400
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City | BOISE
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State | ID
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Zip | 83704-8907
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Country | US
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Telephone | 208-327-5600
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Fax | 208-327-5602
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA61338060
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License Number State | WA
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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 | PA61338060
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 1661274
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License Number State | ID
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