Provider Demographics
NPI:1104573112
Name:WILSON, CASSIE NICOLE (AGCANP)
Entity type:Individual
Prefix:
First Name:CASSIE
Middle Name:NICOLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:AGCANP
Other - Prefix:
Other - First Name:CASSIE
Other - Middle Name:NICOLE
Other - Last Name:STREET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGCANP
Mailing Address - Street 1:PO BOX 31001-2360
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-2360
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1075 N CURTIS RD STE 101
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1348
Practice Address - Country:US
Practice Address - Phone:208-302-2800
Practice Address - Fax:208-302-2825
Is Sole Proprietor?:No
Enumeration Date:2022-03-09
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID66379363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner