NPI age
19 years
Enumerated 2006-06-09
Across 111 active internal medicine providers in Idaho.
| Type | Value | Notes |
|---|---|---|
| 01 (WA) | 0115863 | LABOR AND INDUSTRY |
| 01 (WA) | MD00035287 | STATE LICENSE NUMBER |
| 05 (WA) | 8209629 | |
| 01 | 100010270 | RAILROAD MEDICARE |
Part of a multi-provider practice. 29 other active providers share this practice address in NPPES.
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