Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist |
NPI | 1083249783 |
---|---|
Provider Name | Cameron Conlon |
First Address | Boise, ID 83709-6523 |
Second Address | Boise, ID 83709-6523 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/03/2020 |
Last Update Date | 03/03/2020 |