Provider Demographics
NPI:1235660663
Name:WILSON, IDA MAYS (MD)
Entity type:Individual
Prefix:DR
First Name:IDA
Middle Name:MAYS
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IDA
Other - Middle Name:MAYLYNN
Other - Last Name:MAYS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 9TH AVE # 359796
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2499
Mailing Address - Country:US
Mailing Address - Phone:206-744-3564
Mailing Address - Fax:206-744-8582
Practice Address - Street 1:1333 SURGICAL SERVICES WAY
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-4844
Practice Address - Country:US
Practice Address - Phone:406-751-5392
Practice Address - Fax:406-751-5406
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61288990208600000X
MTMED-PHYS-LIC-1267602086S0102X, 2086S0127X, 208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery