Provider Demographics
NPI:1275748089
Name:WILSON, JARED KENT (PA-C, MPAS, MED, ATC)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:KENT
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA-C, MPAS, MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:777 HOSPITAL WAY
Mailing Address - Street 2:SOUTH MOB, SUITE 204
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5175
Mailing Address - Country:US
Mailing Address - Phone:208-239-2110
Mailing Address - Fax:208-239-2119
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:SOUTH MOB, SUITE 204
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-239-2110
Practice Address - Fax:208-239-2119
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2025-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-4922255A2300X
IDPA-952363AS0400X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer