Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207P00000X | Emergency Physician | M8736 | ID |
N | 207PP0204X | Pediatric Emergency Physician | M8736 | ID |
NPI | 1124065214 |
---|---|
Provider Name | Kenneth Jenson Bramwell |
First Address | Boise, ID 83712-6241 |
Second Address | Boise, ID 83712-6241 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2006 |
Last Update Date | 22/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G76573 | (02) |