Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | MRO-1478 | ID |
Y | 207Q00000X | Family Doctor | O-1008 | ID |
NPI | 1003296724 |
---|---|
Provider Name | Molly M Mccormick |
First Address | Boise, ID 83704-9251 |
Second Address | Kuna, ID 83634-5005 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2015 |
Last Update Date | 21/11/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1003296724 | (05) | ID |