| NPI | 1295283810 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JACQUELINE LEE WAGNER Owner 208-661-1181 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine |
| Additional Taxonomies | 363L00000X Nurse Practitioner |
| Enumeration Date | 2016-09-12 |
| Last Update Date | 2024-03-25 |