| NPI | 1225389414 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | REANNA PARK Billing Specialist 208-525-2090 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-325) |
| Enumeration Date | 2012-09-27 |
| Last Update Date | 2012-09-27 |