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General NPI Number Information
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NPI Number | 1710941026
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Entity Type | Individual
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Provider Name | JON MOORE AGEE M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/13/2006
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Last Update Date | 01/25/2022
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Provider Practice Location Address
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Address Line | 404 E ELM ST
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City | CALDWELL
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State | ID
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Zip | 83605-4846
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Country | US
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Telephone | 208-459-0028
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Fax | 208-459-0380
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Provider Business Mailing Address
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Address Line | PO BOX 742941
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City | ATLANTA
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State | GA
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Zip | 30374-2941
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Country | US
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Telephone |
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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 | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | M-5972
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License Number State | ID
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