Provider Demographics
NPI:1417338104
Name:WILSON, SARA
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 E. ST. LUKES ST.
Mailing Address - Street 2:STE. 200
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6011
Mailing Address - Country:US
Mailing Address - Phone:208-992-5212
Mailing Address - Fax:208-992-5452
Practice Address - Street 1:2960 E. ST. LUKES ST.
Practice Address - Street 2:STE. 200
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6011
Practice Address - Country:US
Practice Address - Phone:208-992-5212
Practice Address - Fax:208-992-5452
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1568A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner