Basic Information
| Provider Information | |||||||||
| NPI: | 1427126127 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WASIELEWSKI | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2963 E COPPER POINT DR | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836429055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083221730 | ||||||||
| FaxNumber: | 2083221731 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 N CURTIS RD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837061309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083672130 | ||||||||
| FaxNumber: | 2083221731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 03/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | EC-05-030 | ME | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD183358 | OR | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | M-10203 | ID | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 808037300 | 05 | ID | MEDICAID |