NPI age
7 years
Enumerated 2018-06-01
Across 326 active specialist/technologist providers in Idaho.
| Type | Value | Notes |
|---|---|---|
| 01 | 2000038852 | BOC NUMBER |
| 01 (ID) | AT-772 | STATE LICENSURE NUMBER |
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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