Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207RC0200X | Critical Care Medicine | 20A15369 | CA |
N | 207RC0200X | Critical Care Medicine | O-1353 | ID |
N | 207RP1001X | Pulmonary Disease | DO198185 | OR |
Y | 207RP1001X | Pulmonary Disease | O-1353 | ID |
NPI | 1013335157 |
---|---|
Provider Name | Wesley David Pidcock |
First Address | Meridian, ID 83642 |
Second Address | Nampa, ID 83687 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/04/2014 |
Last Update Date | 25/11/2020 |