Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207YS0123X | Facial Plastic Surgeon | 5101021036 | MI |
Y | 207YX0905X | Otolaryngology/Facial Plastic Surgery | O-1265 | ID |
NPI | 1871904698 |
---|---|
Provider Name | Matthew Mors |
First Address | Boise, ID 83719-1050 |
Second Address | Boise, ID 83703-2739 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/05/2014 |
Last Update Date | 07/08/2019 |