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General NPI Number Information
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NPI Number | 1548890460
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Entity Type | Organization
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Legal Business Name | MMMEDICAL GROUP LLC.
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Dates
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Enumeration Date | 01/20/2020
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Last Update Date | 09/23/2020
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Provider Practice Location Address
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Address Line | 801 N STILSON RD STE 300
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City | BOISE
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State | ID
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Zip | 83703-5145
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Country | US
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Telephone | 208-332-4540
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5328
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City | BOISE
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State | ID
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Zip | 83705-0328
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Country | US
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Telephone | 208-333-0000
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | RANDY EVARO
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Credential |
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Telephone | 208-333-0000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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