Provider Demographics
NPI:1659638864
Name:WILSON, SARA C (MD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-706-8526
Mailing Address - Fax:
Practice Address - Street 1:701 E PARKCENTER BLVD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6528
Practice Address - Country:US
Practice Address - Phone:208-381-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM12880207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine