| NPI | 1881277200 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MCKENNA DESTEFANO Owner 208-859-8290 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 261QM2500X Clinic/Center, Medical Specialty |
| Enumeration Date | 2021-05-03 |
| Last Update Date | 2021-11-02 |