Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XS0117X | Orthopaedic Spine Surgeon | M9283 | ID |
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | M9283 | ID |
N | 207XX0801X | Orthopaedic Trauma Surgeon | M9283 | ID |
NPI | 1396827150 |
---|---|
Provider Name | Mark A Weight |
First Address | Idaho Falls, ID 83403-1432 |
Second Address | Idaho Falls, ID 83404-7407 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/10/2006 |
Last Update Date | 17/06/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
807238300 | (05) | ID |
I09687 | (02) |