Provider Demographics
NPI:1578518692
Name:WILSON, KATHLEEN WHITE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:WHITE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KALLY
Other - Middle Name:D
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:350 HERITAGE WAY
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3158
Mailing Address - Country:US
Mailing Address - Phone:406-752-5170
Mailing Address - Fax:406-752-5120
Practice Address - Street 1:75 CLAREMONT ST STE A
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3500
Practice Address - Country:US
Practice Address - Phone:406-752-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT266363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT95503OtherBLUE CROSS
MT432610Medicaid
MT432610Medicaid
P43186Medicare UPIN