NPI age
18 years
Enumerated 2007-10-29
Across 504 active internal medicine providers in Idaho.
| Type | Value | Notes |
|---|---|---|
| 05 (ID) | 808577100 | |
| 01 (ID) | P00863516 | MCRR |
| 01 (PA) | OS014238 | LICENSE |
Part of a multi-provider practice. 28 other active providers share this practice address in NPPES.
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