Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | AT-668 | ID |
Y | 213ES0000X | Sports Medicine | AT-668 | ID |
NPI | 1508344201 |
---|---|
Provider Name | Megan Frey |
First Address | Moscow, ID 83844-9803 |
Second Address | Moscow, ID 83844-9803 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/08/2018 |
Last Update Date | 03/08/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2000030678 | NATABOC (01) | CA |