Individual
JACESON BANHAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
3425 POTOMAC WAY, IDAHO FALLS, ID 83404-4984
(208) 528-8170
Mailing address
PO BOX 291, PROVIDENCE, UT 84332-0291
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
—
Other
Enumeration date
01/03/2025
Last updated
01/03/2025
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