Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | CHIA-1370 | ID |
N | 111NN0400X | Neurology | CHIA-1370 | ID |
NPI | 1104055383 |
---|---|
Provider Name | Dr. Maria Teresa Gomez Sirucek |
First Address | Meridian, ID 83642-3544 |
Second Address | Meridian, ID 83642-3544 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/07/2009 |
Last Update Date | 10/01/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1093975302 | (05) | ID |
800265693 | (02) | ID |