| NPI | 1952654741 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JENNIFER RICKELL WILLMORE Owner 208-624-4402 |
| Organization Subpart ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA 519) |
| Enumeration Date | 2012-10-18 |
| Last Update Date | 2013-04-04 |