Provider Demographics
NPI:1164140786
Name:WRIGHT, ALEX STEPHEN (PA)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:STEPHEN
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:COUNCIL
Mailing Address - State:ID
Mailing Address - Zip Code:83612-0428
Mailing Address - Country:US
Mailing Address - Phone:208-253-4242
Mailing Address - Fax:208-253-6849
Practice Address - Street 1:205 N BERKLEY ST
Practice Address - Street 2:
Practice Address - City:COUNCIL
Practice Address - State:ID
Practice Address - Zip Code:83612-5015
Practice Address - Country:US
Practice Address - Phone:208-253-4242
Practice Address - Fax:208-253-6849
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID9361272363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant