Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207XP3100X | Pediatric Orthopaedic Surgeon | O0947 | ID |
N | 207XP3100X | Pediatric Orthopaedic Surgeon | OP60637340 | WA |
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | O0947 | ID |
N | 207XX0005X | Sports Medicine Orthopaedic Surgeon | OP60637340 | WA |
NPI | 1861774291 |
---|---|
Provider Name | Michael David Schicker |
First Address | Ponderay, ID 83852-5005 |
Second Address | Ponderay, ID 83852 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/09/2011 |
Last Update Date | 19/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
807920700 | (05) | ID |
8502734 | (05) | WA |