Individual
SHAY BULLOCK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
NP-C
Contact information
Practice address
33 N. MISSION RD, FORT HALL, ID 83203
(208) 380-9727
Mailing address
33 N. MISSION RD, FORT HALL, ID 83203-8016
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
812099
NV
Other
Enumeration date
12/13/2021
Last updated
07/20/2022
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