Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 19037 | CA |
N | 111NN0400X | Neurology | CH61009706 | WA |
N | 111NN0400X | Neurology | CHIA-1724 | ID |
NPI | 1699726398 |
---|---|
Provider Name | Dr. F. Blake Ambridge |
First Address | Sandpoint, ID 83864-2742 |
Second Address | Sandpoint, ID 83864-2742 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/05/2006 |
Last Update Date | 19/05/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U29246 | (02) | CA |