Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | O-0885 | ID |
N | 207Q00000X | Family Doctor | ED0179A | WV |
NPI | 1194019406 |
---|---|
Provider Name | Michael Anderson |
First Address | Rexburg, ID 83440-2048 |
Second Address | Rexburg, ID 83440-2048 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/06/2011 |
Last Update Date | 02/04/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1346643038 | (05) | ID |