Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | CHIA-459 | ID |
NPI | 1477516169 |
---|---|
Provider Name | Mr. Raymond Keith Mckim |
First Address | Nampa, ID 83686-6311 |
Second Address | Nampa, ID 83686-6311 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
002702400 | (05) | ID |