Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | M6331 | ID |
NPI | 1023094901 |
---|---|
Provider Name | Monte H Moore |
First Address | Boise, ID 83702-4565 |
Second Address | Boise, ID 83702-4565 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/12/2005 |
Last Update Date | 31/01/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
F61825 | (02) | ID |