Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | MRO-1915 | ID |
NPI | 1003438730 |
---|---|
Provider Name | Tracy Adams |
First Address | Boise, ID 83704-9251 |
Second Address | Boise, ID 83704-9251 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/05/2020 |
Last Update Date | 15/05/2020 |