Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208G00000X | Cardiothoracic Vascular Surgeon | 5013 | AK |
Y | 208G00000X | Cardiothoracic Vascular Surgeon | M-11141 | ID |
NPI | 1124004510 |
---|---|
Provider Name | Stephen Donald Jones |
First Address | Meridian, ID 83642 |
Second Address | Boise, ID 83704 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/12/2005 |
Last Update Date | 25/04/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G64747 | (02) |