Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC0200X | Nurse Practitioner - Critical Care Medicine | 54488 | ID |
NPI | 1447820188 |
---|---|
Provider Name | Bryan William Garrett |
First Address | Coeur D Alene, ID 83814-6051 |
Second Address | Coeur D Alene, ID 83814-4401 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/06/2021 |
Last Update Date | 30/07/2021 |