| NPI | 1154610731 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MICHELE JANEE LOUCAO Office Manager 208-893-5383 |
| Organization Subpart ? | No |
| Primary Taxonomy | 174400000X Specialist (Licence: ID M-7753) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ID PA-895) |
| Enumeration Date | 2011-04-04 |
| Last Update Date | 2011-04-04 |