Provider Demographics
NPI:1649024415
Name:WILSON, ALEX ALLEN
Entity type:Individual
Prefix:MR
First Name:ALEX
Middle Name:ALLEN
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5720 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-9578
Mailing Address - Country:US
Mailing Address - Phone:986-888-0566
Mailing Address - Fax:
Practice Address - Street 1:5720 3RD AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-9578
Practice Address - Country:US
Practice Address - Phone:986-888-0566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program