Individual
MR. JEFFERY THOMAS LY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
RN
Contact information
Practice address
11961 PHEASANT RUN ST, CALDWELL, ID 83605-5082
(208) 590-8166
Mailing address
11961 PHEASANT RUN ST, CALDWELL, ID 83605-5082
(208) 590-8166
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
Primary
46147
ID
Other
Enumeration date
03/21/2018
Last updated
03/21/2018
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