Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0122X | Plastic and Reconstructive Surgery | M-8189 | ID |
NPI | 1275772667 |
---|---|
Provider Name | Rebecca D Shaw |
First Address | Meridian, ID 83642-7975 |
Second Address | Meridian, ID 83642-7975 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/02/2009 |
Last Update Date | 09/02/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H44448 | (02) | ID |