Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | MRM-1959 | ID |
NPI | 1003430174 |
---|---|
Provider Name | Emily Davis |
First Address | Pocatello, ID 83201-4880 |
Second Address | Pocatello, ID 83201-4008 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/06/2020 |
Last Update Date | 03/06/2020 |