Provider Demographics
NPI:1508232604
Name:WILSON, PATRICIA ANN (CNIM)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1019 SAGEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2729
Mailing Address - Country:US
Mailing Address - Phone:208-221-0234
Mailing Address - Fax:
Practice Address - Street 1:1019 SAGEWOOD PL
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2729
Practice Address - Country:US
Practice Address - Phone:208-221-0234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
713246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
713OtherCNIM