Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2080N0001X | Neonatal-Perinatal Doctor | 3863 | AZ |
Y | 2080N0001X | Neonatal-Perinatal Doctor | O0424 | ID |
NPI | 1023083680 |
---|---|
Provider Name | Shannon Jenkins |
First Address | Idaho Falls, ID 83404-7531 |
Second Address | Idaho Falls, ID 83404-7531 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/02/2006 |
Last Update Date | 23/12/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0117377 | (05) | MT |
121542600 | (05) | ID |
121542600 | (05) | WY |
1285786046 | (05) | WY |
H80981 | (02) | AZ |
H80981 | (02) | ID |