Provider Demographics
NPI:1083004873
Name:WILSON, ASHLEIGH
Entity Type:Individual
Prefix:
First Name:ASHLEIGH
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASHLEIGH
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:5656 S ONAGA PL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-6865
Mailing Address - Country:US
Mailing Address - Phone:806-674-5736
Mailing Address - Fax:
Practice Address - Street 1:5656 S ONAGA PL
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-6865
Practice Address - Country:US
Practice Address - Phone:806-674-5736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-31
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
TX11914212251P0200X
IDPT-6573225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics