Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2084N0400X | Neurologist | 8482 | MT |
Y | 2084N0400X | Neurologist | M-12653 | ID |
NPI | 1033179288 |
---|---|
Provider Name | Karen Porth |
First Address | Meridian, ID 83642-1026 |
Second Address | Boise, ID 83704 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/03/2006 |
Last Update Date | 21/10/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
121828000 | (05) | WY |