Basic Information
| Provider Information | |||||||||
| NPI: | 1891707360 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | REGENIA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4283 N NINES RIDGE LN | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837021866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083455830 | ||||||||
| FaxNumber: | 2083455830 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 STATE ST | ||||||||
| Address2: | |||||||||
| City: | MCCALL | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836383704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086342221 | ||||||||
| FaxNumber: | 2086347112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RNA109 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 89250 | 01 | ID | BLUE CROSS GROUP # | OTHER | 000010017281 | 01 | ID | REGENCE | OTHER | A4092 | 01 | ID | BLUE CROSS | OTHER |