Provider Demographics
NPI:1649597055
Name:WILLS, ALEX BRENT (MD)
Entity Type:Individual
Prefix:DR
First Name:ALEX
Middle Name:BRENT
Last Name:WILLS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 W BANNOCK ST STE 1100
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6140
Mailing Address - Country:US
Mailing Address - Phone:808-258-3029
Mailing Address - Fax:
Practice Address - Street 1:950 W BANNOCK ST STE 1100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6140
Practice Address - Country:US
Practice Address - Phone:808-258-3029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-24
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IDTL - 40112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program