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General NPI Number Information
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NPI Number | 1407223274
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Entity Type | Individual
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Provider Name | MICHAEL KENNETH WUCINICH PA-C
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Gender | Male
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Dates
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Enumeration Date | 08/28/2015
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Last Update Date | 11/19/2015
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Provider Practice Location Address
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Address Line | 775 POLE LINE RD W STE 302
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City | TWIN FALLS
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State | ID
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Zip | 83301-5823
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Country | US
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Telephone | 208-814-8725
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Fax |
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Provider Business Mailing Address
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Address Line | 3724 E 3770 N
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City | KIMBERLY
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State | ID
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Zip | 83341-5524
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Country | US
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Telephone | 208-420-8188
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Fax |
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 1274
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License Number State | ID
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