Basic Information
Provider Information | |||||||||
NPI: | 1578518692 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILSON | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | WHITE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WHITE | ||||||||
OtherFirstName: | KALLY | ||||||||
OtherMiddleName: | D | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 350 HERITAGE WAY | ||||||||
Address2: | SUITE 1300 | ||||||||
City: | KALISPELL | ||||||||
State: | MT | ||||||||
PostalCode: | 599013158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4067525170 | ||||||||
FaxNumber: | 4067525120 | ||||||||
Practice Location | |||||||||
Address1: | 75 CLAREMONT ST STE A | ||||||||
Address2: |   | ||||||||
City: | KALISPELL | ||||||||
State: | MT | ||||||||
PostalCode: | 599013500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4067528282 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2006 | ||||||||
LastUpdateDate: | 06/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/26/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 266 | MT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 95503 | 01 | MT | BLUE CROSS | OTHER | 432610 | 05 | MT |   | MEDICAID |