Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207KA0200X | Allergist | DO0000002408 | TN |
Y | 207KA0200X | Allergist | O-0796 | ID |
NPI | 1376877795 |
---|---|
Provider Name | David Aaron Petty |
First Address | Idaho Falls, ID 83404-8262 |
Second Address | Idaho Falls, ID 83404-8262 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/10/2009 |
Last Update Date | 21/06/2019 |