Provider Demographics
NPI:1174513188
Name:WILKEY, THAD W (PA)
Entity type:Individual
Prefix:
First Name:THAD
Middle Name:W
Last Name:WILKEY
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 1:2101 N WHITLEY DR
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2132
Mailing Address - Country:US
Mailing Address - Phone:208-452-5999
Mailing Address - Fax:208-452-4499
Practice Address - Street 1:2101 N WHITLEY DR
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2132
Practice Address - Country:US
Practice Address - Phone:208-452-5999
Practice Address - Fax:208-452-4499
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA280363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010147742OtherBLUE SHIELD
IDPACC2OtherBLUE CROSS
ID806348800Medicaid
ID000010139188OtherBLUE SHIELD
IDPACB4OtherBLUE CROSS
IDPANX1OtherBLUE CROSS
ID000010138646OtherBLUE SHIELD
ID970026445OtherRAILROAD MEDICARE
IDPACB4OtherBLUE CROSS
ID806348800Medicaid