Provider Demographics
NPI:1619863404
Name:ADVANCED WOUND THERAPY - IDAHO, PLLC
Entity type:Organization
Organization Name:ADVANCED WOUND THERAPY - IDAHO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARDESTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-803-1190
Mailing Address - Street 1:2488 E 81ST ST STE 2000
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-4224
Mailing Address - Country:US
Mailing Address - Phone:918-592-9020
Mailing Address - Fax:
Practice Address - Street 1:1224 N IDAHO ST STE 9
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-9024
Practice Address - Country:US
Practice Address - Phone:918-592-0920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty