Provider Demographics
NPI:1689743700
Name:WILSON, HILLARY GUTHRIE (PAC)
Entity Type:Individual
Prefix:
First Name:HILLARY
Middle Name:GUTHRIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-955-6500
Mailing Address - Fax:208-955-6501
Practice Address - Street 1:11197 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-7935
Practice Address - Country:US
Practice Address - Phone:208-378-8011
Practice Address - Fax:208-322-8095
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1535363A00000X, 363A00000X
IDPA-2217363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
12428227OtherCAQH
NV1689743700Medicaid