NPI age
20 years
Enumerated 2006-05-16
Across 260 active surgery providers in Idaho.
| Type | Value | Notes |
|---|---|---|
| 01 (ID) | M7975 | STATE LICENSE # |
| 05 (ID) | 805748100 | |
| 01 | 020445995 | RAILROAD MEDICARE |
Part of a multi-provider practice. 2 other active providers share this practice address in NPPES.
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