Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080N0001X | Neonatal-Perinatal Doctor | O-1399 | ID |
NPI | 1114346749 |
---|---|
Provider Name | Jordan Simpson |
First Address | Ammon, ID 83406-1268 |
Second Address | Idaho Falls, ID 83404-7533 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2014 |
Last Update Date | 27/08/2020 |