Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 100508 | ID |
NPI | 1013534890 |
---|---|
Provider Name | Brent Sexauer |
First Address | Mountain Home, ID 83647-2134 |
Second Address | Boise, ID 83706-3503 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2020 |
Last Update Date | 29/06/2020 |