NPI age
19 years
Enumerated 2006-09-25
Across 1691 active family medicine providers in Idaho.
| Type | Value | Notes |
|---|---|---|
| 01 (ID) | M-7205 | STATE LICENSE |
| 05 (ID) | 1346341351 | |
| 01 (ID) | CS-7048 | IDAHO CONTROLLED SUBSTANC |
Part of a multi-provider practice. 21 other active providers share this practice address in NPPES.
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