NPI age
19 years
Enumerated 2007-03-08
Across 305 active specialist providers in Idaho.
| Type | Value | Notes |
|---|---|---|
| 01 (ID) | M6902 | LICENSE |
| 05 (ID) | 805168100 |
Part of a multi-provider practice. 4 other active providers share this practice address in NPPES.
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