Provider Demographics
NPI:1962962118
Name:SEMONCHUK, WESLEY ADAM
Entity type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:ADAM
Last Name:SEMONCHUK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3080 E GENTRY WAY STE 210
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3013
Mailing Address - Country:US
Mailing Address - Phone:208-384-9022
Mailing Address - Fax:
Practice Address - Street 1:3080 E GENTRY WAY STE 210
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3013
Practice Address - Country:US
Practice Address - Phone:208-384-9022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-23
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1958363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant