| NPI | 1699364455 |
|---|---|
| Doing Business As | N/A |
| Entity Type | Organization |
| Authorized Contact | KRISTYN DICE Contracting Manager 208-717-3944 |
| Organization Subpart ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363LF0000X Nurse Practitioner, Family | |
| Enumeration Date | 2021-01-15 |
| Last Update Date | 2023-07-13 |