Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | AT2887175 | DE |
Y | 207P00000X | Emergency Physician | O-0980 | ID |
N | 207R00000X | Internist | AT2887175 | DE |
N | 111NI0900X | Internist | AT2887175 | DE |
NPI | 1003934100 |
---|---|
Provider Name | Matthew Judd |
First Address | Meridian, ID 83642-9055 |
Second Address | Boise, ID 83706-1309 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2007 |
Last Update Date | 25/09/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003934100 | (05) | ID |