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General NPI Number Information
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NPI Number | 1679382600
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Entity Type | Organization
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Legal Business Name | SOUTHERN IDAHO WOUND CARE PLLC
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Dates
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Enumeration Date | 01/03/2025
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Last Update Date | 01/03/2025
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Provider Practice Location Address
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Address Line | 242 N 4200 E
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City | RIGBY
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State | ID
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Zip | 83442-5977
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Country | US
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Telephone | 858-382-2764
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 575
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City | LEWISBURG
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State | PA
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Zip | 17837-0575
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KUSHALJIT DHESI
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Credential | MD
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Telephone | 858-382-2764
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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