NPI age
17 years
Enumerated 2008-06-12
Across 1691 active family medicine providers in Idaho.
1 secondary location on file with NPPES.
| Type | Value | Notes |
|---|---|---|
| 01 (ID) | M-11689 | MEDICAL LICENSE |
| 05 (ID) | 1245490390 |
Solo or small practice. No other active providers share this practice address in NPPES.
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