NPI age
19 years
Enumerated 2007-05-14
Across 22 active internal medicine providers in Idaho.
| Type | Value | Notes |
|---|---|---|
| 01 (CA) | BO872W | MEDICARE PTAN |
| 01 (CA) | A104590 | MEDICAL LICENSE |
Part of a multi-provider practice. 223 other active providers share this practice address in NPPES.
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