Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RR0500X | Rheumatology | M4525 | ID |
NPI | 1003847633 |
---|---|
Provider Name | Dr. James Robert Polk |
First Address | Boise, ID 83702-3049 |
Second Address | Boise, ID 83706-1352 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/07/2006 |
Last Update Date | 08/07/2007 |