Provider Demographics
NPI:1538164272
Name:WOLF, JAMES A (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:A
Last Name:WOLF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6208
Mailing Address - Country:US
Mailing Address - Phone:208-342-7033
Mailing Address - Fax:208-342-7034
Practice Address - Street 1:341 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6208
Practice Address - Country:US
Practice Address - Phone:208-342-7033
Practice Address - Fax:208-342-7034
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM82722086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8061001Medicaid
IDM8272OtherSTATE MEDICAL LICENSE
ID82-0535217OtherFEDERAL EIN
IDM8272OtherSTATE MEDICAL LICENSE
IDD95159Medicare UPIN