Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207ND0101X | MOHS-Micrographic Surgeon | M11491 | ID |
NPI | 1245484096 |
---|---|
Provider Name | Kurtis B Reed |
First Address | Boise, ID 83712-6241 |
Second Address | Twin Falls, ID 83301-5812 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/11/2008 |
Last Update Date | 22/09/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1245484096 | (05) | ID |
ENROLLED | (05) | IA |
ENROLLED | (05) | MN |
P00873574 | RAILROAD MEDICARE (01) | MN |