NPI age
18 years
Enumerated 2007-08-20
Across 260 active surgery providers in Idaho.
| Type | Value | Notes |
|---|---|---|
| 05 (ID) | 004008900 | |
| 05 (ID) | 1115888 |
Solo or small practice. No other active providers share this practice address in NPPES. This provider is listed as a sole proprietor.
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