Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | CHIA-1276 | ID |
NPI | 1669654935 |
---|---|
Provider Name | Dr. Dax Sirucek |
First Address | Meridian, ID 83642-3544 |
Second Address | Meridian, ID 83642-3544 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/11/2007 |
Last Update Date | 21/06/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1682024 | (02) | ID |