Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | MD61238314 | WA |
N | 207QH0002X | Family Doctor - Hospice and Palliative Medicine | MD61238314 | WA |
NPI | 1104879899 |
---|---|
Provider Name | Shana D Fogarty |
First Address | Coeur D Alene, ID 83814-6051 |
Second Address | Coeur D Alene, ID 83814-6051 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2006 |
Last Update Date | 22/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
I25953 | (02) | ID |
P00204201 | RAILROAD MEDICARE (01) | ID |