Provider Demographics
NPI:1538565270
Name:WILDING, JOSHUA KEITH (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:KEITH
Last Name:WILDING
Suffix:
Gender:M
Credentials:PA-C
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 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-955-6500
Mailing Address - Fax:
Practice Address - Street 1:1623 S WELLS AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5040
Practice Address - Country:US
Practice Address - Phone:208-498-1050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-07
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108385363A00000X
IDPA-1744363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant