Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 3714 | IA |
N | 111NI0900X | Internist | 3714 | IA |
Y | 207RI0200X | Infectious Disease | O-0530 | ID |
NPI | 1083716153 |
---|---|
Provider Name | Casi Mcpherson Wyatt |
First Address | Boise, ID 83712-6212 |
Second Address | Boise, ID 83712-6212 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/09/2006 |
Last Update Date | 09/06/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0731364 | (05) | IA |
26705 | WELLMARK BCBS (01) | IA |
I62496 | (02) | IA |