| NPI | 1326528977 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | PHILLIP EUGENE STEVENSON Organizer 208-936-0303 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: WY PT764) |
| Enumeration Date | 2018-08-14 |
| Last Update Date | 2018-08-14 |