Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | PA-1924 | ID |
Y | 213ES0000X | Sports Medicine | PA-1924 | ID |
NPI | 1003461401 |
---|---|
Provider Name | Noah Bernal |
First Address | Ammon, ID 83406-4707 |
Second Address | Idaho Falls, ID 83404-7573 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/08/2019 |
Last Update Date | 28/08/2020 |