Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife |
NPI | 1154657096 |
---|---|
Provider Name | Ian Penwell |
First Address | Boise, ID 83713-5185 |
Second Address | Boise, ID 83713-5185 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/10/2009 |
Last Update Date | 28/10/2009 |