Provider Demographics
NPI:1992322382
Name:WILKES, DALLIN SCOTT (DPT)
Entity type:Individual
Prefix:
First Name:DALLIN
Middle Name:SCOTT
Last Name:WILKES
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4032 S FEDERAL WAY APT E101
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-5250
Mailing Address - Country:US
Mailing Address - Phone:208-230-2762
Mailing Address - Fax:
Practice Address - Street 1:2175 N WHITLEY DR.
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619
Practice Address - Country:US
Practice Address - Phone:208-452-7197
Practice Address - Fax:208-452-4811
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID6741225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist