NPIMap

Individual provider Active NPI

Audra Lynn Wilson, PAC

  • Physician Assistant
  • Boise, ID
National Provider Identifier
1336734789
Registry record updated Dec 10, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
1661274 Issued in ID
Practice address
6140 W Curtisian Ave Ste 400
Boise, ID 83704-8907
Phone
(208) 327-5600
Fax
(208) 327-5602
NPI assigned
Mar 8, 2021
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 10, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X PA61338060 WA
Surgical Physician Assistant 363AS0400X PA61338060 WA
Physician Assistant 363A00000X 1661274 ID Primary

Addresses

Primary practice location

6140 W Curtisian Ave Ste 400
Boise, ID 83704-8907

Mailing address

6140 W Curtisian Ave Ste 400
Boise, ID 83704-8907
Phone (208) 327-5600

Other identifiers 1

IdentifierTypeStateIssuer
2215177MedicaidWA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA, ID2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20220916001499 WA Practitioner - Physician Assistant 8123403854 Reassigns benefits to 1 organization
I20241211003613 ID Practitioner - Physician Assistant 8123403854 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Des Moines University of Osteopathic Medicine and Health Sciences, 2022
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Kelly Bridges Neurosurgery PLLCGroup PAC ID 0648502617, 2 clinicians

Practice addresses (Care Compare)

1055 N Curtis Rd
Boise, ID 83706-1309
Phone (208) 367-2121

6140 W Curtisian Ave
Suite 400
Boise, ID 83704-8907
Phone (208) 327-5600

Hospital & facility affiliations

  • Treasure Valley Hospital Hospital, Boise, ID, CCN 130063
  • Saint Alphonsus Regional Medical Center Hospital, Boise, ID, CCN 130007

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
1661274IDMDPhysician Assistant
PA61338060WAMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Proliance Surgeons Inc P S Physician Assistant Current Accepting new patients
Proliance Surgeons Inc., P.S. CurrentSince Sep 11, 2023 Accepting new patients
Proliance Surgeons Inc P S Surgical CurrentSince Sep 11, 2023 Accepting new patients
Proliance Surgeons, Inc., P.S. Physician Assistant CurrentSince Sep 11, 2023 Accepting new patients

Locations

3801 5th St SE
Ste 110
Puyallup, WA 98374
Phone (253) 845-9585

805 Madison St
Ste 901
Seattle, WA 98104
Phone (206) 264-8100

Interoperability endpoints

  • Direct secure messaging: audra.wilson.p83@direct.proliance.nextgenshare.com

Organizations & group practices 5

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1615161600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1733788800000",
    "number": "1336734789",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6140 W CURTISIAN AVE STE 400",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837048907",
            "telephone_number": "208-327-5600",
            "fax_number": "208-327-5602"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6140 W CURTISIAN AVE STE 400",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837048907",
            "telephone_number": "208-327-5600",
            "fax_number": "208-327-5602"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WILSON",
        "first_name": "AUDRA",
        "middle_name": "LYNN",
        "credential": "PAC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2021-03-08",
        "last_updated": "2024-12-10",
        "certification_date": "2024-12-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "WA",
            "license": "PA61338060",
            "primary": false
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "WA",
            "license": "PA61338060",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "ID",
            "license": "1661274",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2215177",
            "state": "WA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Boise, ID

Sources for this page

Verify at the official NPI Registry.