Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | M-5527 | ID |
Y | 208600000X | Surgeon | M-5527 | ID |
N | 2082S0105X | Plastic Hand Surgeon | M-5527 | ID |
NPI | 1447368758 |
---|---|
Provider Name | Dr. William P.d. Wilson III |
First Address | Idaho Falls, ID 83404-7531 |
Second Address | Idaho Falls, ID 83404-7531 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/08/2006 |
Last Update Date | 20/02/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
EO7079 | (02) |