Provider Demographics
NPI:1497931562
Name:WIMMER, PAIGE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:PAIGE
Middle Name:
Last Name:WIMMER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:686 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5458
Mailing Address - Country:US
Mailing Address - Phone:208-392-3472
Mailing Address - Fax:
Practice Address - Street 1:686 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5458
Practice Address - Country:US
Practice Address - Phone:208-392-3472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-18
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12068171100000X
IDACU-233171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist