Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | CHIA1203 | ID |
NPI | 1164524658 |
---|---|
Provider Name | Dr. Brady Matthew Wirick |
First Address | Idaho Falls, ID 83404 |
Second Address | Idaho Falls, ID 83404-8322 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/09/2006 |
Last Update Date | 19/10/2007 |