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General NPI Number Information
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NPI Number | 1285258186
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Entity Type | Individual
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Provider Name | JESSE SAMPOGNA DPT
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Gender | Male
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Dates
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Enumeration Date | 06/05/2020
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Last Update Date | 06/05/2020
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Provider Practice Location Address
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Address Line | 9508 W FAIRVIEW AVE
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City | BOISE
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State | ID
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Zip | 83704-8103
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Country | US
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Telephone | 208-323-1313
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Fax |
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Provider Business Mailing Address
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Address Line | 6023 S KELSO WAY
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City | BOISE
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State | ID
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Zip | 83709-4055
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Country | US
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Telephone | 208-789-7763
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT-6709
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License Number State | ID
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