1275748089 NPI number — JARED KENT WILSON PA-C, MPAS, MED, ATC

Table of content: JARED KENT WILSON PA-C, MPAS, MED, ATC (NPI 1275748089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275748089 NPI number — JARED KENT WILSON PA-C, MPAS, MED, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
JARED
Provider Middle Name:
KENT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C, MPAS, MED, ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275748089
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
777 HOSPITAL WAY
Provider Second Line Business Mailing Address:
SOUTH MOB, SUITE 204
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83201-5175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-239-2110
Provider Business Mailing Address Fax Number:
208-239-2119

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
777 HOSPITAL WAY
Provider Second Line Business Practice Location Address:
SOUTH MOB, SUITE 204
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83201-5175
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-239-2110
Provider Business Practice Location Address Fax Number:
208-239-2119
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  AT-492 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: PA-952 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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