Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081P2900X | Pain Medicine | M6287 | ID |
NPI | 1154345585 |
---|---|
Provider Name | Dr. Clinton Mallari |
First Address | Boise, ID 83702-7302 |
Second Address | Boise, ID 83702-7302 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/07/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B48394 | (02) | ID |