Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | NP956A | ID |
NPI | 1003817701 |
---|---|
Provider Name | Ms. Jayne S Shoda |
First Address | Coeur D Alene, ID 83814 |
Second Address | San Fernando, CA 91340 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/08/2005 |
Last Update Date | 18/12/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
Q04196 | (02) |